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This is an enhanced PDF from The Journal of Bone and Joint Surgery
2011;93:10-20. doi:10.2106/JBJS.J.01243J Bone Joint Surg Am.
Robert F. LaPrade, Steinar Johansen and Lars Engebretsen
Surgical Technique
Outcomes of an Anatomic Posterolateral Knee Reconstruction:
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Copyright © 2011 by The Journal of Bone and Joint Surgery, Incorporated
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than
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J Bone Joint Surg Am. 2011;93 Suppl 1:10-20 • doi:10.2106/JBJS.J.01243
Outcomes of an Anatomic
Posterolateral Knee Reconstruction
Surgical Technique
By Robert F. LaPrade, MD, PhD, Steinar Johansen, MD, and Lars Engebretsen, MD, PhD
Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota,
and the Department of Orthopaedic Surgery, Ullevaal University Hospital, University of Oslo, Oslo, Norway
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 92-A, pp. 16-22, January2010
ABSTRACT FROM THE ORIGINAL ARTICLE
BACKGROUND: Chronic posterolateral knee injuries often result in substantial patient morbidity and functional instability.
The clinical stability and functional outcomes following anatomic reconstructions in patients with a chronic posterolateral
knee injury have not been determined, to our knowledge.
METHODS: A two-center outcomes study of sixty-four patients with grade-3 chronic posterolateral instability was per­
formed. The patients were evaluated subjectively with the modified Cincinnati and International Knee Documentation
Committee (IKDC) subjective scores and objectively with the IKDC objective score.
RESULTS: Eighteen patients had an isolated posterolateral knee reconstruction, and forty-six patients underwent a single-
stage multiple-ligament reconstruction that included reconstruction of one or both cruciate ligaments along with the
posterolateral knee reconstruction. The average duration of follow-up was 4.3 years. The fifty-four patients who were
available for follow-up had an average total Cincinnati score of 65.7 points. A significant improvement was found between
the preoperative and postoperative IKDC objective scores for varus opening at 20°, external rotation at 30°, reverse pivot
shift, and single-leg hop.
CONCLUSIONS: An anatomic posterolateral reconstruction resulted in improved clinical outcomes and objective stability for
patients with a grade-3 posterolateral knee injury.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
ORIGINAL ABSTRACT CITATION: “Outcomes of an Anatomic Posterolateral Knee Reconstruction” (2010;92:16-22).
INTRODUCTION
In chronic posterolateral knee
injuries, primary repair of
stretched or avulsed structures is
not possible. Therefore, a recon-
struction of torn posterolateral
corner knee structures is neces-
sary. Our group has developed
and validated an anatomic re-
construction of the fibular col-
lateral ligament, the popliteus
tendon, and the popliteofibular
ligament1,2
. An overview of this
technique follows.
SURGICAL TECHNIQUE
The patient is brought to the
operating theater and receives ei-

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The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
ther a general, epidural, or spinal
anesthetic. Once anesthesia has
set in, it is important to perform
a thorough evaluation of the
knee. The examination with the
patient under anesthesia should
assess all knee ligaments to verify
the possible presence of any con-
current ligament injuries. This
examination includes an evalu-
ation of patellofemoral stabil-
ity, valgus stress testing in full
extension and at 30° of flexion,
a Lachman test and a posterior
drawer test, varus stress testing
in both full extension and at
30° of flexion, the reverse and
regular pivot shift tests, the pos-
terolateral drawer test, and the
dial test3-7
. The results of these
tests are synthesized to verify
that the findings of the earlier
clinical examination match those
of the examination with the
patient under anesthesia. Once
this is confirmed, the procedure
proceeds. First, a tourniquet is
placed around the proximal part
of the thigh. The patient is then
positioned on the operating ta-
ble. It is very important to make
sure that a sandbag is placed and
taped to the table such that the
knee can sit in a neutral position
(usually in about 75° to 80° of
knee flexion) without the need
for assistants to hold it during
the operation. A sandbag must
also be placed under the ipsilat-
eral hip to assist with intraopera-
tive positioning (Fig. 1). Once
the intraoperative positioning
has been verified, the surgical
procedure can commence. The
patient is given prophylactic
antibiotics, and the affected ex-
tremity is prepared and draped
in the usual sterile manner. Be-
fore the surgical procedure com-
mences, a “time out” is called to
verify the patient’s name and the
operative extremity.
The initial incision can
be performed with or without
a tourniquet, depending on
whether concurrent procedures
may be performed. The incision
is centered over the posterior to
midportion of the iliotibial band
and is carried out distally to over
the anterior compartment, cross-
ing the joint at approximately
the level of Gerdy’s tubercle1,2,8
.
The incision is carried down
through the skin and the under-
lying subcutaneous tissues to
identify the superficial layer of
the iliotibial band (Fig. 2). Once
the superficial layer of the ilio-
tibial band is identified, a very
meticulous dissection of the soft
tissues is performed posteriorly
over the long and short heads of
the biceps femoris. It is impor-
tant to obtain hemostasis at this
time and also to meticulously
dissect in this area to minimize
postoperative bleeding. Once the
long head of the biceps femoris
has been identified, attention
is turned toward perform-
ing a common peroneal nerve
neurolysis.
A common peroneal neu-
rolysis is performed in all pa-
tients to ensure that the nerve
can be retracted adequately
when the reconstruction tun-
nels are drilled2
and to release
the nerve from scar tissue
entrapment. The nerve is usu-
ally located by palpation ap-
proximately 2 to 3 cm distal
to the long head of the biceps
Fig. 1
A left knee positioned prior to surgery.

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femoris. Sometimes, when there
is excessive scar tissue, a more
extensive and slower peroneal
nerve neurolysis must be per-
formed. In these cases, the nerve
is often found by palpating ap-
proximately 2 cm distal to the
lateral aspect of the fibular head.
In this area, the fascia over the
peroneus longus muscle is re-
leased to identify the nerve. The
nerve should be decompressed
for approximately 8 cm in total
length (Fig. 3). This allows it to
be retracted gently out of the
operative field when necessary
and also facilitates access to the
posterior aspect of the knee.
Once the common pero-
neal nerve neurolysis has been
performed, as described above,
blunt dissection is carried out
between the lateral head of the
gastrocnemius muscle and the
soleus (Fig. 4). It is through this
interval that one can palpate
the posteromedial aspect of the
fibular head and also identify the
region of the musculotendinous
junction of the popliteus tendon
and the popliteofibular liga-
ment. It is important to identify
both of these structures for the
placement of the reconstruction
tunnels.
The next incision is per-
formed to identify the fibular
collateral ligament attachment
site on the fibular head. It is
made directly through the an-
terior arm of the long head of
the biceps and extends into the
biceps bursa, approximately 1
cm proximal to the fibular head.
Through this incision, one can
identify the fibular collateral
ligament attachment site on the
fibular head1,2,9
. A stitch is placed
into the substance of the fibular
collateral ligament to allow trac-
tion to be placed on it to assist
with identification of its proxi-
Fig. 2
The surgical approach with retraction of the superficial layer of the iliotibial band (right
knee).
Fig. 3
A common peroneal nerve neurolysis (right knee).

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mal attachment site (Fig. 5).
Once the biceps bursa has
been entered and the course of
the fibular collateral ligament
has been identified, the anterior
aspect of the anterior arm of the
long head of the biceps femoris
is dissected subperiosteally off
the fibular head. Gentle release
of the remnants of the fibular
collateral ligament attachment
on the lateral aspect of the fibu-
lar head is performed. There is a
small “saddle” in this area where
the ligament attaches on the fib-
ular head1,2,10
. Once this attach-
ment site is identified, one can
identify the attachment site of
the popliteofibular ligament on
the posteromedial aspect of the
fibular head. Next, attention is
turned toward drilling the fibu-
lar head reconstruction tunnel.
A standard cruciate liga-
ment aiming device is used to
drill the tunnel for the fibular
collateral ligament in the fibula.
The lateral aspect of the aim-
ing device is placed directly at
the fibular collateral ligament
attachment site on the lateral
aspect of the fibular head, and
the medial aspect of the cruciate
ligament aiming device is placed
on the posteromedial downslope
of the fibular styloid, at the re-
gion of attachment of the pop-
liteofibular ligament. A retractor
is then inserted to prevent guide-
pin protrusion medially, and a
guide pin is drilled through the
guide. Next, the guide should
be removed to verify by finger
palpitation that these entry and
exit sites of the guide pin are in
the desired position. Finally, this
tunnel is over-reamed with a
7-mm reamer and the entry and
exit sites are chamfered with a
rasp (Fig. 6).
Attention is next turned
toward drilling the tibial recon-
struction tunnel. First, a meticu-
lous release of tissues from the
Fig. 5
Through the horizontal incision in the biceps bursa, a traction stitch is placed into the
lax fibular collateral ligament (left knee).
Fig. 4
Blunt dissection between the lateral gastrocnemius and soleus muscles is used to
allow identification of the popliteofibular ligament by palpation (left knee).

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distal aspect of the superficial
layer of the iliotibial band is
performed to identify Gerdy’s
tubercle. There is a flat area of
bone that is just distal and me-
dial to Gerdy’s tubercle. This
location is also just lateral to the
lateral aspect of the patellar ten-
don and proximal to the tibial
tubercle. Direct downward dis-
section onto bone will identify
this flat spot. A small rongeur or
elevator is then used to clean the
soft tissues off this area because
it will serve as the entry site for
the tibial tunnel.
Next, the musculotendi-
nous junction of the popliteus
muscle is identified10
. It is im-
portant to make sure that one
is submuscular and against the
cortex of the posterolateral as-
pect of the lateral tibial plateau.
A blunt obturator from the ar-
throscopy system is placed into
the fibular head tunnel to serve
as a reference landmark to assist
with identification of the muscu-
lotendinous junction landmarks.
The reconstruction tunnel in the
tibia should be approximately 1
cm medial and 1 cm proximal to
the exit site of the fibular head
reconstruction tunnel1,2,10
. The
popliteus musculotendinous
junction can now be identified
either by direct palpation or by
using an elevator to elevate the
popliteus musculature at this
location.
An anterior cruciate liga-
ment (ACL) aiming device is
used to aim the guide pin from
the anterior tibial entry site,
which is just distal and medial to
Gerdy’s tubercle, to the exit site
Fig. 7
The cruciate aiming device is used to guide placement of the tibial tunnel guide pin.
Note that an obturator has been placed into the fibular head tunnel to assist with guide-
pin placement (left knee).
Fig. 6
The location of the fibular head reconstruction tunnel (adjacent to the forceps) along
the lateral aspect of the fibular head (left knee).

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posteriorly at the musculoten-
dinous junction of the popliteus
(Fig. 7). A retractor is placed
posteriorly to prevent guide-
pin overpenetration. The guide
pin is drilled from anterior to
posterior. Once the ACL aiming
device is removed, one should
palpate posteriorly, while at the
same time placing the blunt ob-
turator in the fibular tunnel, to
verify that the guide pin is both
at the exact center of the mus-
culotendinous junction of the
popliteus and also that it is ap-
proximately 1 cm medial and 1
cm proximal to the obturator.
Attention is then turned to
the identification of the femoral
attachment sites of the popliteus
tendon and the fibular collateral
ligament. The surgeon should
tug on the substance of the fibu-
lar collateral ligament with the
traction suture and should try to
palpate exactly where the lateral
epicondyle and the attachment
site of the fibular collateral liga-
ment are located on the femur10
.
Once this site is identified, the
iliotibial band is split in line with
its fibers with a number-15 knife
blade. It is better to make this
incision slightly anterior to the
lateral epicondyle rather than
posterior to it in order to make
sure that adequate traction can
be provided. Once the attach-
ment site of the fibular collateral
ligament is identified, or the
lateral epicondyle is identified,
the remnants of the fibular col-
lateral ligament are dissected off
the femoral attachment site. This
attachment site is approximately
3.2 mm proximal and posterior
to the lateral epicondyle10
. Once
again, there is a small depres-
sion where the fibular collateral
ligament attaches on the femur,
Fig. 9
The location of the femoral reconstruction tunnels for the popliteus tendon (to the left)
and the fibular collateral ligament (to the right) (left knee).
Fig. 8
The islet passing pins enter the femur at the anatomic attachment sites of the
popliteus tendon and fibular collateral ligament (left knee).

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The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
and one should try to identify
it. Once the attachment site of
the fibular collateral ligament is
identified, a cruciate ligament
aiming device is placed across
the knee with the guide pin en-
tering right at the attachment
site of the fibular collateral liga-
ment and exiting anteromedially
along the thigh. It is important
to make sure that this guide pin
does not exit directly across the
knee toward the medial epi-
condyle because it could pass
through the intercondylar notch.
It is also important to make sure
that this guide pin exits ante-
riorly rather than posteriorly
where it could injure the saphe-
nous nerve.
The next step in the proce-
dure is to identify the popliteus
tendon attachment site on the
femur. The surgeon palpates the
anterior aspect of the popliteal
hiatus or measures 2 cm anterior
to the native course of the fibu-
lar collateral ligament to iden-
tify where the vertical incision
should be made in the lateral
capsule. If one cannot palpate
the popliteal hiatus, its location
can be identified by placing a
knife handle along the course of
the fibular shaft when the knee
is flexed to 70°. At this posi-
tion, it should follow the native
course of the fibular collateral
ligament. One can then measure
2 cm anteriorly to identify the
portion of the lateral capsule
through which one can place
the vertical incision. Once this
incision is made, the joint is en-
tered and the popliteus tendon
attachment site on the top fifth
of the popliteal hiatus is identi-
fied10
. If the popliteus tendon has
been avulsed from this area, it is
important to verify that one has
sufficient retraction to identify
the top fifth of the popliteal hia-
tus11
. The cruciate ligament aim-
ing device is used to drill an islet
passing pin transversely across
the femur, exiting anteromedi-
ally and parallel to the fibular
collateral ligament islet passing
pin (Fig. 8).
A very important step in
this procedure is to measure
between the two islet passing
pins to confirm the correct dis-
tance between them. The aver-
age distance between the two
guide pins should be 18.5 mm,
thus restoring the normal ana-
tomic relationship between the
fibular collateral ligament and
the popliteus tendon femoral
attachment sites10
. Once the
normal distance between these
attachment sites is identified, a
9-mm reamer is used to ream to
a depth of 25 mm for the recon-
struction tunnels. Next, the soft
tissues around the tunnel aper-
tures are cleaned so that they do
not interfere with graft passage
into the tunnels (Fig. 9).
At this point, all four re-
Fig. 10
The grafts are prepared for the posterolateral reconstruction.

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The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
construction tunnels have been
reamed and the surgeon can
turn to the intra-articular por-
tion of the procedure and surgi-
cally address any pathologies
there, including meniscal repairs,
partial meniscectomies, and cru-
ciate ligament reconstructions.
When cruciate ligament recon-
struction is performed, the re-
construction tunnels are reamed
and the grafts are fixed in the
femoral tunnels. After these in-
tra-articular abnormalities have
been addressed, attention can re-
turn to the posterolateral corner
reconstruction.
While the surgeon is per-
forming the intra-articular
portion of the procedure, an
assistant can prepare the pos-
terolateral corner reconstruction
grafts. We use a split Achilles
tendon allograft (Fig. 10). The
calcaneal bone portion of the
graft is split down the middle,
and the tendon is separated
into two grafts. The grafts must
be prepared such that they will
fit through the reconstruction
tunnels that have been reamed
previously. Also, two separate
9-mm-diameter by 25-mm-long
bone plugs are prepared from
the calcaneus. The distal aspects
of the Achilles tendon are tubu-
larized to make sure that they
will fit through the reconstruc-
tion tunnels. The initial 70 mm
of the fibular collateral ligament
graft and 60 mm of the poplit-
eus tendon graft are left slightly
thicker to accommodate for the
native length of these struc-
tures1,2,10
. The portion of the
grafts that will be entering into
bone should be trimmed slightly
to allow them to pass through
the tunnels readily. Passing su-
tures are placed in both the soft-
tissue portion of the grafts as
well as the bone plugs.
Once the two posterolateral
corner reconstruction grafts have
been prepared, the posterolat-
eral corner reconstruction grafts
are passed into their appropri-
ate tunnels. First, the grafts are
placed into the femoral tunnel.
The graft passage technique is
very similar to endoscopic ACL
reconstruction graft passage.
Next, the sutures are placed into
the end of each corresponding
islet pin and are pulled trans-
versely across the femur. Then
the bone plugs are pulled into
their femoral tunnels (Fig. 11),
and each is fixed in place with
a 7-mm by 20-mm cannulated
titanium screw. In order to pass
the guide pin for the cannulated
screw into the reconstruction
tunnel, it should be placed in a
drill chuck or a hand-held chuck
with approximately 3 cm of the
guide pin sticking out. This fa-
cilitates placing the guide pin
between the bone plug and the
reconstruction tunnel for the
cannulated reconstruction screw.
Once both bone plugs have been
fixed in the femur, a solid lateral
traction tug is applied to both
grafts to verify that there is good
graft purchase.
Next, the popliteus tendon
graft is passed down into the
popliteal hiatus. It should exit
the posterolateral aspect of the
knee at the region of the poplit-
eus musculotendinous junction
and should be passed out of the
surgical incision anterior to the
Fig. 11
The placement of the popliteus tendon and fibular collateral ligament grafts into the
femoral tunnels (right knee).

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The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
lateral head of the gastrocne-
mius. This graft is then left in
place until the fibular collateral
ligament graft is secured in its
fibular tunnel. The fibular col-
lateral graft is passed distally
under the superficial layer of the
iliotibial band and the lateral
aponeurosis of the long head
of the biceps (Fig. 12). It can be
passed through the fibular head
tunnel. Either a suture passer or
a suture can be placed through
the fibular head tunnel to assist
with graft passage. Once the ends
of the fibular collateral grafts are
placed in the fibular head tunnel,
attention is directed toward pos-
terior cruciate ligament (PCL)
reconstruction graft fixation on
the tibia when appropriate.
If there is a concurrent PCL
reconstruction being performed,
the PCL graft is now fixed to
the tibia to restore the native
central pivot of the knee. Once
the PCL graft has been secured,
attention is turned toward fixing
the fibular collateral ligament
graft in the fibular head tun-
nel. It is important to make sure
that there is no lateral compart-
ment gapping when fixing the
graft. Thus, appropriate tension
should be applied proximally on
the remnant of this graft, which
protrudes from the posterome-
dial aspect of the fibula. Also, a
valgus reduction force should
be applied to the knee, and the
knee should be held in neutral
rotation. A bioabsorbable screw
is then used to secure the fibu-
lar collateral ligament graft in
the fibular head tunnel with the
knee flexed to 20° (Fig. 13). It is
very important at this point to
perform an examination with
the patient under anesthesia to
verify that the varus instability
has been completely eliminated.
Once the examination with
Fig. 12
The popliteus tendon graft is passed down the popliteal hiatus, and the fibular collateral
ligament graft is passed under the superficial layer of the iliotibial band (right knee).
Fig. 13
The interference screw is placed into the fibular head tunnel to secure the fibular
collateral ligament graft (right knee).

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The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
the patient under anesthesia
confirms that the fibular col-
lateral ligament reconstruction
graft has eliminated all varus
gapping, two remaining ends
of both of the grafts are passed
from posterior to anterior
through the tibial tunnel. The
remaining portion of the fibular
collateral ligament graft now
becomes the popliteofibular
ligament reconstruction graft.
A passing stitch or other device
can be used to pull both grafts
out anteriorly. It is very impor-
tant to cycle the grafts to make
sure that all slack has been re-
moved from them. One should
also palpate at the entry site of
the tibial tunnel posteriorly to
verify that there is no bunching
of the tissue. Once it is verified
that all slack is out of the grafts,
the grafts can be fixed in the
tibial tunnel.
The grafts are fixed in the
tibial tunnel with the knee flexed
to approximately 60°, in neutral
rotation, and with traction on
both grafts individually (Fig.
14). Then a 9-mm bioabsorb-
able screw is placed in the tibial
tunnel. Next, the surgeon should
verify that there is a negative pos-
terolateral drawer test and/or res-
toration to a normal amount of
external rotation compared with
the contralateral knee. At this
point, a backup staple is placed
over the grafts and into the tibia
to provide security for fixation of
the popliteofibular ligament and
popliteus tendon grafts.
Once any concurrent PCL
reconstruction and the postero-
lateral corner reconstructions are
fixed in their respective tunnels,
the ACL graft can be fixed in its
tibial tunnel. It is important not
to fix the ACL graft prior to fixa-
tion of the posterolateral recon-
struction grafts because there is a
risk of creating an excessive fixed
external rotation deformity12
.
After all of the grafts have
been secured in their reconstruc-
tion tunnels, any excess graft
is excised. The subcutaneous
tissues can then be closed with
absorbable sutures, followed
by an absorbable subcuticular
stitch, and loose taping of the
skin edges. Finally, we place an
immobilizer on the knee prior to
waking the patient from anesthe-
sia to make sure that no injury
occurs to the reconstruction as
the patient awakens.
CRITICAL CONCEPTS
INDICATIONS:
• Acute midsubstance tears of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament that cannot
be repaired
• Chronic tears of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament
continued
Fig. 14
Interference screws secure the popliteus tendon and popliteofibular ligament grafts to
the tibia (right knee).

12. 
The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org
Robert F. LaPrade, MD, PhD
Steadman Philippon Research Institute, 181 West
Meadow Drive, #1000, Vail, CO 81657. E-mail
address for R.F. LaPrade: drlaprade@sprivail.org
Steinar Johansen, MD
Lars Engebretsen, MD, PhD
Department of Orthopaedic Surgery, Ullevaal
University Hospital, University of Oslo, N-0407 Oslo,
Norway
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2006;34:553-64.
12. Wentorf FA, LaPrade RF, Lewis JL,
Resig S. The influence of the integrity of
posterolateral structures on tibiofemoral
orientation when an anterior cruciate
ligament graft is tensioned. Am J Sports
Med. 2002;30:796-9.
13. Arthur A, LaPrade RF, Agel J. Proximal
tibial opening wedge osteotomy as the
initial treatment for chronic posterolateral
corner deficiency in the varus knee: a
prospective clinical study. Am J Sports Med.
2007;35:1844-50.
14. Noyes FR, Barber-Westin SD, Hewett
TE. High tibial osteotomy and ligament
reconstruction for varus angulated anterior
cruciate ligament-deficient knees. Am J
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15. Pietrini SD, LaPrade RF, Griffith CJ,
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CRITICAL CONCEPTS (CONTINUED)
CONTRAINDICATIONS IN PATIENTS WITH ACUTE INJURIES:
• Extensive injury to the subcutaneous tissues or skin whereby it is difficult to safely make an incision
• Associated abrasions or open lacerations over the area of the surgical incision
• Active infection
CONTRAINDICATIONS IN PATIENTS WITH CHRONIC INJURIES:
• Severe knee osteoarthritis
• Patients with uncorrected varus alignment of the ipsilateral extremity
RECONSTRUCTION PITFALLS:
• For patients with varus alignment, it is very important to correct the varus alignment first with an osteotomy; otherwise,
there is a very high risk of the grafts stretching out11,13,14
• The surgeon should assess the size of the fibular head to determine if the reconstruction tunnel diameter may need to
be decreased from 7 to 6 mm.
• For patients who have an avulsion fracture of the fibular head, also called an arcuate fracture, the fibular
reconstruction tunnel locations may need to be adjusted more distally to compensate for the fracture.
• Acute injuries with extreme scarring or chronic injuries with soft-tissue adhesions around the common peroneal nerve
can add substantially to the operative time.
• In patients with chronic injuries, especially those undergoing revisions, it may be difficult to assess the location of the
reconstruction tunnels if they have been obliterated by previous surgical procedures.
• When reconstruction tunnels have been obliterated, intraoperative fluoroscopy may be needed to identify the
attachment sites of the critical structures to verify that they are being placed back into the correct positions15
.
• The surgeon should assess the position of the common peroneal nerve intraoperatively and verify that traction is not
applied to the nerve during the operative procedure to avoid a postoperative footdrop.
AUTHOR UPDATE:
There have been no substantial changes or modifications to this procedure since our original report.