**4. Arthroscopic posterolateral corner stabilization with popliteus tenodesis**

#### **4.1 Indications and contraindications**

Indication for this procedure is a posterolateral rotatory instability of the knee grade A according to Fanelli and Larson classification (**Table 2**) [22]. It can also be used in grade B and C PLRI as a part of combined procedure with reconstruction of other structures of the PLC. The main purpose of this technique is to prevent excessive tibial external rotation. Secondly, it allows to reduce posterior tibial subluxation caused by PLC injury.

*Injuries of the Posterolateral Corner of the Knee-Diagnosis and Treatment Options for Beginning… DOI: http://dx.doi.org/10.5772/intechopen.99219*

The contraindications are: damaged femoral attachment of PLT, complete midsubstance PLT tear without scar formation, excessive varus deformity of the knee, advanced osteoarthritis, rheumatoid arthritis.

#### **4.2 Rationale for using arthroscopic PLT tenodesis**

The rationale for using arthroscopic PLT tenodesis are facts that most popliteus tears are extra-articular, involving usually the muscle or myotendinous portion and in chronic cases sulcus popliteus is usually covered by popliteus tendon and/ or scar tissue [7, 12]. Thus, the PLT is still presented in its anatomical location, despite losing its function. Moreover, it has been proved that anatomic reconstruction of the passive part of PLT significantly restores proper range of tibial external rotation [24].

Presented technique does not require advanced skills in arthroscopic surgery, is safe and reproducible, does not exhaust other surgical options.

#### **4.3 Arthroscopic PLT tenodesis-surgical technique**

The patient is positioned supine with a thigh tourniquet applied on operated leg, which is placed in a leg holder. The procedure is performed using standard anterolateral (AL) and anteromedial (AM) portals. After arthroscopic inspection of whole knee joint and excluding other intra-articular pathologies, the arthroscope is inserted to the lateral knee recess and PLT unit is visualized (**Figure 4**). With the knee in full extension an additional mid-lateral portal is placed 1,5 cm above the fibular head, just anterior or posterior to FCL depending on better angle of attack determined with a marking needle (**Figure 5**). It is important to stay anterior to BT to avoid common peroneal nerve injury. Then, under visual control, Pean's forceps with fastened one end of suture tape (FiberTape, Arthrex, GmBH Munich, Germany) are inserted behind the PLT to the posterolateral knee recess, the tape is introduced to lateral knee compartment using an arthroscopic grasper and then it is pulled out the joint through mid-lateral portal with Pean's forceps making a ring around the PLT at the level of planned place for tenodesis (**Figure 6**). The ideal point for PLT fixation is the crossing of the horizontal line at the tip of fibular head with vertical line at the medial edge of fibular head, 1 cm below the joint line [7].

#### **Figure 4.**

*Arthroscopic view from anterolateral viewing portal in the right knee with the arthroscope in lateral knee recess. Popliteus muscle-tendon unit may be observed. PLT- popliteus tendon, PFL- popliteofibular ligament, LM- lateral meniscus.*

#### **Figure 5.**

*A marking needle is used to determine the proper place for mid-lateral portal placement in the right knee. FHfibular head, FCL- fibular collateral ligament.*

#### **Figure 6.**

*Arthroscopic view from anterolateral viewing portal in the right knee. Suture tape (ST) rounded the popliteus tendon (PLT) right before making a tenodesis. LFC- lateral femoral condyle, LM- lateral meniscus.*

In this place the proximal part of tibial popliteus aiming guide (senior author K. H prototype) is fixed and the distal part is positioned on the anteromedial tibial cortex, just below the pes anserinus where a small skin incision is made. Both parts of the aiming guide are connected and the eyelet pin is drilled through tibia (**Figure 7**). For advanced arthroscopic surgeons it is possible to drill the tibia with an eyelet pin using a free-hand technique after positioning the tip of pin in the proper place for PLT fixation which was previously described. Then, using a 6 mm drill, a 2-cm depth bone sockets are formed in the posterolateral and anteromedial cortex of the tibia. After that, free ends of suture tape rounding PLT are passed through the eye in an eyelet pin and the pin is pulled-out through the anteromedial tibial cortex introducing the PLT into bone socket. Free ends of suture tape are tied on the cortical button placed in the socket on the anteromedial tibial cortex. The tension of tenodesis is regulated by twisting the cortical button with Pean's forceps under arthroscopic control until the drive-through sign and lateral meniscus elevation are eliminated in the figure-of-four position (**Figures 8** and **9**).

*Injuries of the Posterolateral Corner of the Knee-Diagnosis and Treatment Options for Beginning… DOI: http://dx.doi.org/10.5772/intechopen.99219*

#### **Figure 7.**

*The right knee. The tibial popliteus aiming guide (K.H prototype) is positioned from posterolateral to anteromedial tibial cortex and the eyelet pin is being used to drill the tunnel.*

### **4.4 Postoperative rehabilitation**

After surgery the knee is immobilized in a brace with limited knee extension (30–90°) for 6 weeks. Passive knee motion starts from the second day after surgery. Walking on crutches is recommended for 6 weeks after surgery. Supervised rehabilitation program with experienced physiotherapist is advised. The rehabilitation protocol is similar to this widely-accepted for PCL reconstructions.

#### **4.5 Advantages and disadvantages of PLT tenodesis**

The main advantage of arthroscopic PLT tenodesis is that this is a minimal invasive technique utilizing native, vascularized material present in the joint. It does not require harvesting grafts and does not exhaust other treatment options. It allows to restore static PLT function. Presented technique does not demand advanced arthroscopic skills and may be useful for beginning arthroscopic surgeons treating PLRI with dominant external rotation component. Following described technique it is a safe procedure because is performed far from common peroneal nerve and does not require maneuvering in the posterior knee close to the popliteal neuro-vascular bundle. Positioning the tunnel in the tibia from posterolateral to anteromedial facilitates utilizing this surgery without special instruments making it a cost-effective procedure.

#### **Figure 8.**

*Tensioning of the tenodesis by twisting the cortex button with Pean's forceps until the drive-through sign is eliminated.*

#### **Figure 9.**

*Eliminated drive-through sign. LFC- lateral femoral condyle, LM- lateral meniscus, LTP- lateral tibial plateau.*

Main disadvantage of presented technique is that it is limited to grade A PLRI and higher grades with varus instability require additional FCL reconstruction. Moreover, reconstruction of PFL is not possible. Being focused on static PLT

function, its dynamic function may be lost. Furthermore, there is a risk of PLT or LM injury during mid-lateral portal formation. It is also worth noting that knee extension deficit may exclude applying this technique.
