Collateral Lateral Ligament (CLL) Tensioning and Posterolateral (PL) Capsular Shift in Chronic PL Knee Instability. Description of a New Surgical Technique.

Authors:

Juan M. Mosquera F. MD
Centro Médico la Carolina. Bogotá. Colombia.
Manuel Mosquera A. MD
Centro Médico la Carolina. Bogotá. Colombia.

Corresponding author: email: mfma1032@gmail.com

The lead author (MMA) declares a conflict of interest as an instructor for knee courses offered by Promed-LATAM.

INTRODUCTION

Chronic posterolateral (PL) instability of the knee is a disabling condition resulting from unsuccessful primary treatment or, more commonly, from an overlooked diagnosis of the injury.¹ It is usually associated with other ligament injuries, mainly posterior cruciate ligament (PCL) injury, followed by anterior cruciate ligament (ACL) injury, and may occur as part of multiligament knee injuries.²

The diagnosis of instability is primarily clinical, considering that magnetic resonance imaging (MRI) is not the best examination for confirming the diagnosis because, in many cases, the main structures forming the posterolateral corner are present: the lateral collateral ligament (LCL), the popliteofibular ligament (PFL), and the popliteus tendon (PT). These structures are usually reported as normal, but they may have healed in an elongated position, resulting in instability.

A varus stress radiograph may confirm an LCL injury if greater opening, measured in millimeters, of the lateral compartment is observed compared with the contralateral healthy side.⁴

The conventional treatment for symptomatic chronic posterolateral knee instability is reconstruction using tendons, involving at least two of the three anatomical structures mentioned above, with tunnels created in the femoral epicondyle and fibular head and, in some techniques, an additional tunnel in the tibia.⁵˒⁶ All described techniques have reported excellent results in controlling varus and external rotation.^7,8,9

In the 2015 expert consensus on the treatment of acute posterolateral knee instability,¹⁰ it was concluded that ligament avulsions had good outcomes when repaired, but not when the injury was located in the midsubstance. In these cases, the consensus recommended repairing the ligament and adding a tendon graft augmentation, or alternatively not repairing it and performing tendon reconstruction. These techniques have comparatively better outcomes than repair alone. The same consensus recommended performing a valgus-producing tibial osteotomy in chronic cases when there is dynamic varus alignment (varus thrust), prior to reconstructive surgery.¹¹

There is currently a trend toward adding ultra-high-strength tapes under the concept of the “Internal Brace” (IB)® during reconstructive and repair procedures, with good results.^{12,13,14,15,16}

Most published studies concerning the treatment of chronic posterolateral instability are based on reconstructive techniques, the most popular being the modified Larson,¹⁷ Arciero,¹⁸ and LaPrade¹⁹techniques. The first two reconstruct the LCL and PFL, while the latter additionally reconstructs the PT. All have demonstrated good results.²⁰

Very few studies have been published regarding posterolateral capsular plication,^21,22 and there are no published studies describing techniques for LCL tensioning.

TECHNIQUE DESCRIPTION

The advantages of the proposed surgical technique are:
Use of the original tissue.
No need for autograft harvesting or allograft use.
No ligamentization process.
Avoidance of tunnel creation.
Preservation of the original collagen.
Preservation of the vascular network.
Preservation of mechanoreceptors.

The rationale for the described procedure is that when the structures of the posterolateral corner are present but elongated, they may:

Regain tension when shortened, plicated, and reinserted.
Eliminate joint instability while maintaining the normal anatomy of the knee.
Substantially decrease procedural morbidity without compromising the outcome.

The described surgical technique is indicated for mild to moderate rotational, varus, or combined instability, provided that the main structures—the LCL, PFL, and PT—are present but elongated.

Surgical technique: step-by-step

No tourniquet is used.
The knee is positioned in flexion on the operating table.
A wide lateral golf-stick incision is made from the epicondyle to the fibular head.
The iliotibial band (ITB) and posterolateral capsule are dissected, creating two layers: a posterior layer, which is plicated, and an anterior layer.
The common peroneal nerve is released.
The lateral collateral ligament (LCL) is identified.
The LCL is detached, 0.5 cm is resected, and anatomical reinsertion is performed using a threaded knotless implant.
An anchor loaded with two or three sutures is inserted into the fibular head, followed by plication of the posterolateral capsule, including the biceps femoris complex, from
posterior to anterior and from proximal to distal. The ITB is then closed.
Elimination of lateral joint gapping and posterolateral drawer of the knee is achieved.

REHABILITATION

Rehabilitation begins on the same day, with isometric exercises to improve muscular control, decrease atrophy, and achieve early extension.

During the first week, passive and active-assisted movements are initiated to regain flexion.
Full weight-bearing of the affected extremity is restricted for 4 weeks. Weight-bearing is subsequently increased until external support is discontinued between 8 and 12 weeks.
Strengthening and proprioceptive exercises are progressively increased.
Jogging is initiated after 20 weeks.
Return to sport-specific movements occurs between 24 and 36 weeks.
Return to sports is allowed after 9 to 12 months, according to objective criteria.

COMPLICATIONS

The possible complications of the procedure are:

Peroneal nerve compression.
Joint stiffness.
Residual instability.

It is essential to release the peroneal nerve at its course along the lateral and posterior aspect of the fibular head in order to prevent compression during posterolateral capsular plication. To prevent stiffness, flexion-extension movements are initiated early.

We consider the described technique to be a viable alternative for the treatment of mild to moderate chronic posterolateral knee instability, with less morbidity for the patient.

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