**5.4 Minimally invasive anatomic FCL reconstruction-surgical technique**

The procedure starts from harvesting gracilis tendon (GT-T). The graft is prepared and double folded on the suspensory cortex device. Then, with the knee in 90° of flexion, a 4–5 cm horizontal skin incision is done above the femoral FCL attachment and 3 cm vertical skin incision is made above the fibular head. Subcutaneous tissues are dissected to bony landmarks. An eyelet pin is placed in the native FCL femoral attachment just proximal and posterior to the lateral femoral epicondyle and used to direct the femoral tunnel toward the point above the medial femoral epicondyle. The drill matched to the size of GT-T graft is used to create femoral tunnel. Then, the eyelet pin is used to introduce the passing suture into the femoral tunnel. In the second step, the eyelet pin is placed in the middle of fibular head and used to position the fibulo-tibial tunnel from this point toward the point just below the MCL tibial insertion (**Figure 11**). The drill matched to the

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

#### **Figure 11.**

*Minimally invasive approach to fibular collateral ligament reconstruction. An eyelet pin and drill guide matched to the size of the graft are used to create tibial tunnel. Passing suture introduced to femoral tunnel may be observed.*

size of the GT-T graft is used to create the tunnel and an eyelet pin is utilized to pass the second passing suture through the fibulo-tibial tunnel. The GT-T graft is passed through fibulo-tibial tunnel from medial to lateral, then passed below the skin and ITB using Pean's forceps and finally introduced into femoral tunnel using the first passing suture (**Figure 12**). The graft is fixed on medial femoral cortex with suspensory device, in the femoral FCL attachment and fibular head using 2 interference screws and additionally on the anteromedial tibial cortex using cortical button (**Figure 13**). In this way the FCL reconstruction is performed.

#### **5.5 Postoperative rehabilitation**

Postoperative rehabilitation protocol is similar to this described previously for arthroscopic PLT tenodesis.

#### **5.6 Advantages and disadvantages**

The main advantage of presented technique is that this is an anatomic reconstruction of the most important PLC structures with limited invasiveness and faster

#### **Figure 12.**

*The gracilis tendon graft is passed through tibial tunnel from medial to lateral, then passed below the skin and ITB and introduced to femoral tunnel using passing suture.*

recovery in comparison to classic open surgeries. Both procedures can be performed as isolated surgeries. Moreover, fibular part of this technique may be used to stabilize the proximal tibio-fibular joint in case of instability. An another asset of this procedure is that there is no need for maneuvering in posterior knee compartment.

Despite its efficacy and many advantages, presented technique has also some disadvantages. Firstly, there is no possibly to reconstruct PFL in presented way. Secondly, more advanced surgical skills and some experience are required to perform it properly. Moreover, graft harvesting is required what can lead to donorsite morbidity. Improper tunnel positioning may lead to MCL symptoms as well as tunnel convergence during cruciate ligaments reconstructions in the future. Finally, in opposition to arthroscopic PLT tenodesis it is a costly procedure.
