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Bulletin of the NYU Hospital for Joint Diseases 2007;65(2):106-14

Posterolateral Corner Injuries of the Knee

Joshua B. Frank, M.D., Thomas Youm, M.D., Robert J. Meislin, M.D., and
Andrew S. Rokito, M.D.

Abstract
The posterolateral region of the knee is an anatomically
complex area that plays an important role in the stabilization
of the knee relative to specific force vectors at low angles of
knee flexion. A renewed interest in this region and advanced
biomechanical studies have brought additional understanding of both the anatomy and the function of posterolateral
structures in knee stabilization and kinematics. Through
sectioning and loading studies, the posterolateral corner
has been shown to play a role in the prevention of varus
angulation, external rotation, and posterior translation.
The potential for long-term disability from these injuries
may be related to increased articular pressure and chondral
degeneration. The failure of the reconstruction of cruciate
ligaments may be due to unrecognized or untreated posterolateral corner injuries. Various methods of repair and reconstruction have been described and new research is yielding
superior results from reconstruction of this region.

solated injuries to the posterolateral corner of the knee

are rare and represent less than 2% of all ligamentous
injuries.1 These injuries are much more common as
part of a multiligamentous pattern. Combined injury patJoshua B. Frank, M.D., was Administrative Chief Resident in
the NYU Hospital for Joint Diseases Department of Orthopaedic
Surgery, NYU Hospital for Joint Diseases, New York, New York.
Thomas Youm, M.D., was an Attending at the NYU Hospital for
Joint Diseases, New York, New York. Robert J. Meislin, M.D., is
Assistant Professor of Orthopaedic Surgery, New York University
School of Medicine, and an Attending in the Shoulder and Elbow
and Sports Medicine Services. Andrew S. Rokito, M.D., is Assistant
Professor of Orthopaedic Surgery, New York University School
of Medicine, and Chief of the Shoulder and Elbow Service, NYU
Hospital for Joint Diseases, New York, New York.
Correspondence: Andrew S. Rokito, M.D., Suite 1402, 301 E.
17th Street, NYU Hospital for Joint Diseases, New York, New
York 10003.

terns have been demonstrated in 43% to 80% of patients

with posterolateral injuries.2-4 The anatomy and function
of this region has gained the recent interest of researchers. Anatomic dissections and subsequent biomechanical
studies have demonstrated discrete ligamentous structures,
which Seebacher and colleagues5 subsequently organized
into three distinct layers. With improved comprehension
of the anatomy and function of this region, one may better
diagnose and treat these injuries. The role of surgical intervention is related to the potential for disability from chronic
posterolateral instability. In addition, this injury pattern may
affect the success of cruciate ligament reconstruction and,
potentially, to advanced degeneration.

Anatomy and Functional Biomechanics

Multiple investigators have delineated the anatomy of this
region. Seebacher and associates5 provided a detailed layer
concept by dividing the structures into three layers, akin
to the medial aspect of the knee. The first, being the most
superficial, contains the iliotibial tract (ITT) and the biceps
femoris. While the ITT is fundamentally thought of as inserting into Gerdys tubercle, there are actually three insertions.
One insertion blends into the intermuscular septum and
inserts onto the supracondylar tubercle via Kaplans fibers.
The second inserts onto the patella and patellar ligament and
the third inserts onto Gerdys tubercle.6 The first layer is also
composed of the superficial aspect of the biceps femoris.
The biceps consists of a long and short head and also has
numerous insertions. The major insertion runs posteriorly to
the ITT and inserts on the fibular head. The second layer is
deep to the first and consists of the quadriceps retinaculum,
anteriorly, as well as the patellofemoral ligaments, posteriorly.5 The third layer, the deepest, can also be divided into a
superficial and deep lamina. Superficial are the lateral collateral ligament (LCL) and the fabellofibular ligament.7 The
deep lamina of the third layer contains the popliteofibular
ligament (PFL), arcuate ligament, and the popliteus muscle

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107

and tendon complex.5

Deep Anatomy (Fig. 1)
The LCL originates from the lateral distal femoral condyle
and inserts onto the lateral aspect of the fibular head. The
femoral site of origin is posterior to the popliteus origin8 and
the fibular site of insertion is distal to the insertions of the
arcuate and PFL. The popliteus originates from the posterior
aspect of the proximal tibia and passes through a hiatus in the
coronary ligament (capsular attachment to the outer edge of
the meniscus) as it inserts onto the lateral femoral condyle,
inferior to the LCL origin. In addition, less than 20% of the
population has attachments between the popliteus tendon
and the lateral meniscus, which may aid in lateral meniscal
movement and stabilization.9
The PFL connects the popliteus tendon to the posterior, proximal region of the fibular head. Its critical role
in posterolateral stability has been extrapolated by recent
research.10 The arcuate ligament is a Y-shaped ligament with
medial and lateral limbs. The lateral portion is formed from
the fascial condensation over the posterior popliteus tendon.5
Additional structures have been defined in this region that
may contribute to posterolateral stability. These include
the middle third of the capsular ligament, the lateral head
of the gastrocnemius tendon, the lateral meniscus, and the
posterolateral joint capsule.
Another reason for the complexity of the posterolateral
region is the variability of the ligaments. A study by Sudasna
and Harnsiriwattanagit11 demonstrated only 68% of knees
had a fabellofibular ligament and 24% had an identifiable
arcuate ligament; however, in 98% of specimens, a fibular
origin of the popliteus was identified, the PFL. Seebacher and
coworkers5 also noted variations. The posterolateral region
of the knee was reinforced by only the arcuate ligament in
13% of knees and the fabellofibular ligament was the sole
reinforcement in 20%. The investigators noted that 67% of
knees had both structures. The fabellofibular ligament and
the arcuate ligament may have an inverse relationship that
embraces the nature of the fabella itself. In patients with a
bony fabella present, a thick fabellofibular ligament was
present in 82.8% of specimens. Furthermore, if the fabellofibular ligament was greater than 5 mm thick, the arcuate
ligament was not present in any of the specimens. Conversely, in patients with a thin or indefinable fabellofibular
ligament, 77.9% had a fabella with an elastic nature. In
addition, a thin, or ill-defined fabellofibular ligament was
accompanied by a well-defined arcuate ligament in 61.9%
of specimens.12 Further evidence of the wide range of variability in the anatomy of this region was demonstrated by
Watanabe and colleagues,13 who classified this region into
seven major variants
All of the significant effort to define the structures of the
posterolateral corner of the knee has given researchers and
clinicians a better understanding of the functional biomechanics of the knee.

Figure 1 Oblique view of the deep layer of the posterolateral

corner of the knee. Modified from Chen FS, Rokito AS, Pitman MI.
Acute and chronic posterolateral rotatory instability of the knee. J
Am Acad Orthop Surg. 2000;8(2):97-110, with permission.

Overall, the posterolateral region of the knee provides

anatomical restraint to varus forces, posteriorly directed
forces, and external rotation forces. The contribution of
each of the individual structures has been examined through
anatomic dissection combined with sectioning studies. The
main stabilizers of this region are the LCL, the PFL, and the
popliteus muscle-tendon complex.
Superficially, the function of the ITT varies with knee
flexion. With the knee in full extension, the ITT is an anterior structure. As the knee flexes, the ITT moves posteriorly
and, thus, exerts an external rotation and posteriorly directed
force on the lateral aspect of the tibia.6 The biceps femoris
functions to provide lateral stabilization as well as a dynamic
external rotation force.14
The LCL offers a primary restraint to varus angulation

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and a secondary restraint to external rotation and posterior

displacement.15 The PFL has a cross-sectional area similar
to that of the LCL (6.9 mm2 vs. 7.2 mm2).16 Various studies
have shown the PFL to be consistently present.11,16 Sectioning
studies have revealed the role of the PFL is to resist excessive
posterior translation, varus angulation, and external rotation
(primary and coupled).15 Under direct varus loading, the
LCL fails first, followed by the PFL, and then the popliteus
muscle belly.16
Through the work of multiple investigators,10,17-25 it has
been shown that sectioning of the posterolateral corner
increases varus rotation, primary external rotation, primary
posterior translation, and coupled external rotation (which
combines movement in more than one plane; in this case,
posterior translation with external rotation). The contribution of this region is mostly at lower angles of knee flexion.
While the LCL is the primary restraint to varus at all angles
of flexion, the contribution of the remainder of the posterolateral structures is greatest at 30 of knee flexion.22
The effect of this region on in situ posterior cruciate
forces is also important. After complete sectioning of the
posterolateral structures, tibia varus or external rotation
causes increased force in the posterior cruciate ligament
(PCL) between 45 and 90 of flexion.22 Internal rotation
force does not affect the PCL; however, after sectioning
the posterolateral structures, the anterior cruciate ligament
(ACL) does experience increased force at 0 to 20 of flexion
on internal rotation.22
The converse may be true as well. The posterolateral
structures experience increased forces when the PCL is
compromised. Under posterior tibial load, the forces in the
posterolateral structures increase from the intact state to the
PCL-deficient state. In the intact knee, the forces decrease
as the knee is flexed, which corresponds to the increased
contribution of the PCL in high angles of flexion. After
sectioning the PCL, the posterolateral structures experience
increased forces at all levels of flexion. Under these conditions, the popliteus muscle acts as a major stabilizer.26

Clinical Relevance
Injury patterns predict both the clinical examination and the
subsequent functional outcome. Isolated PCL injuries have
long been thought to be clinically insignificant. That being
said, it appears as though PCL injuries are not uncommon;
1% to 44% of all knee injuries involve PCL tears.27 With
these injuries, there is an increase in posterior translation,
which increases on higher knee flexion; however, there is no
increase in varus laxity or external rotation.7 Isolated LCL
tears demonstrate increased varus laxity (1 to 4), greatest
at 30; however, the clinical implications of this have been
difficult to define.7
Effect on knee function from injury varies widely. Injury
to all of the posterolateral structures, with the PCL remaining
intact, demonstrates maximally increased varus, external
rotation, and posterior translation at 30 of knee flexion.

As the knee is flexed up to 90, the majority of PCL fibers

become taut, and there is some secondary restraint to varus
and external rotation. At 90 of flexion, there is primary
restraint to posterior translation.17,23,28 When the PCL and
the posterolateral structures are torn, the effect of the PCL
at high angles of flexion is lost, and the knee experiences
decreased restraint to varus, external rotation, and posterior
translation at all angles of flexion.7,23 When ACL injuries are
combined with posterolateral corner injuries, the knee may
experience increases in anterior and posterior translation,
varus, coupled external rotation, and primary internal rotation.25,29
The clinical implications of injuries to this region relate to
the outcome of cruciate reconstruction, as well as an effect on
articular pressure and subsequent degeneration. Vogrin and
colleagues30 looked at in situ PCL forces in the intact knee,
compared to the posterolaterally-deficient knee, under the
testing condition of a posteriorly directed tibial force and an
external rotation force. The PCL experienced higher loads
when the posterolateral structures were sacrificed.
In relation to ACL reconstruction, OBrien and associates31 demonstrated the most common cause of failure of
ACL reconstruction was unrecognized or untreated posterolateral rotatory instability. Noyes and coworkers32 also
illustrated the importance of the posterolateral corner in ACL
reconstruction. They showed that 17 of 76 revision ACL
reconstructions demonstrated unrecognized posterolateral
rotatory instability.
Articular pressure also increases with ligament sectioning. Combined sectioning of the PCL and posterolateral
complex increases patellofemoral pressures. Additionally,
the posterior subluxation of the tibia, or drop back, leads
to increased quadriceps contraction required to extend the
knee. Further, PCL sectioning leads to increased medial
compartment pressures.33

Mechanism of Injury
Acute isolated posterolateral knee injuries are extremely
rare and represent less than 2% of all ligamentous knee
injuries.1 The majority of these injuries occur as part of a
combined injury pattern. The mechanism of injury usually
relates to contact or noncontact mechanisms. Contact, or
direct, injuries are due to sports (40%) or motor vehicle
accidents. A posterolaterally directed force is exerted onto
the proximal medial tibia, causing knee hyperextension with
varus and external rotation. Noncontact mechanisms also
involve a forceful hyperextension of the knee with concurrent tibial external rotation. Foot position may also play an
important role. With the ankle in dorsiflexion, a fall results
in the majority of the force moving through the patella;
however, with plantarflexion, the proximal tibia strikes the
ground or object.
Posterolateral corner injuries are rarely isolated. Concurrent ligamentous injury rate has been shown to range from
29% to 80%.1,4,34,35 Magnetic resonance imaging studies35

Bulletin of the NYU Hospital for Joint Diseases 2007;65(2):106-14

have revealed the potential for internal derangements of the

knee that include both meniscal tears (29%) and osteochondral lesions (36%).

Presentation and Examination

The acutely injured patient will present with complaints
of pain, effusion, and possibly gross deformity if a knee
dislocation is present. Ecchymosis or skin abrasions on the
anteromedial proximal tibia may be signs of a posterolateral
injury. Motor or sensory symptoms in peroneal nerve distribution have been reported in 14% to 30% of patients.14,36
Pulses and ankle-brachial indices (ABI) measures should be
evaluated, as vascular injury also may be present.
The presentation of posterolateral injury will vary according to its acuity. Compared to the acute trauma setting, a
chronic injury will most likely cause instability. In addition,
there may be lateral joint line pain and difficulty with lateral
movements or cutting activities.14,37
The physical examination for both settings should start
with inspection of the overall limb alignment, limb length,
and gait pattern. Varus malalignment of the extremity may
not only predispose a person to posterolateral corner injury,
but may lead to failure of treatment as well. With full extension or gait, the knee may buckle into hyperextension. Due
to this instability, patients may ambulate with the knee in
a flexed position. Patients also hold the ankle in equinus to
prevent the knee from reaching full extension. A lateral or
varus knee thrust may be visible.14,37
A variety of physical examination tests have been described for both posterior cruciate and posterolateral injuries.
The basis for these tests stems from the aforementioned function of each region. It is important to understand the correct
position of the knee for each test and to have a systematic
approach in clinically evaluating the patient. The knee should
be tested first for anterior-posterior laxity. The anterior and
posterior drawer and Lachman tests are designed to evaluate
the integrity of the cruciate ligaments. If either the PCL or
posterolateral corner is injured, the knee may have assumed
a posteriorly subluxed position. Anterior translation from
this position can lead to a falsely positive anterior drawer
or Lachman test.38 This posterior resting position also leads
to anterior translation of the tibia with quadriceps contraction, known as the quadriceps active test. The normal knee
does not demonstrate this motion. The posterior drawer can
be used to evaluate the PCL if done with the knee at 90 of
flexion. At 30 of flexion, the test can be used to evaluate
the posterolateral corner.
Varus and valgus laxity testing should be performed in full
extension and then at 30 of flexion to isolate the collateral
ligaments. Since the posterolateral corner resists posterior
translation, external rotation, and varus at lower degrees
of knee flexion, some combination of these movements
are present in the individualized tests.39 The posterolateral
drawer sign is similar to the posterior drawer except the leg
is externally rotated, approximately, 15. The posteriorly

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directed force causes the lateral tibia plateau to move while

the medial plateau does not translate.40 The external rotation
recurvatum test is performed by lifting the extremity by the
great toe. A knee with a posterolateral corner injury should
fall into hyperextension, varus, and external rotation.3
A variety of additional tests are available. The posterior
external rotation test is a combination of a posterior force
and an external rotation force, performed at 30 and 90 of
knee flexion. Positive results at 30 indicate a posterolateral
corner injury; however, positive results at 90 may be indicative of combined posterolateral corner and PCL injuries.41
The dynamic posterior shift test is performed with the patient
supine and the hip and knee flexed. The knee is then passively
extended. A clunk or jerk can be felt as the tibia is reduced
to near full extension.42 With posterior lateral corner injuries,
there may also be an appreciable element of rotation of the
tibia on reduction.
The tibial external rotation test, or dial test, is performed
at 30 and 90 of knee flexion. A supine or prone body position can be used. The relationship of the medial aspect of
the foot to the femoral axis is examined. The normal values
allow for 29 (10 to 45) of external rotation at 30 of
knee flexion. At 90 of knee flexion, tibial external rotation
increases in normal subject to 37 (15 to 70).37 As this test
also correlates to the presence of ligamentous laxity, the most
useful application is a comparison between the affected and
contralateral extremities.43 Jakob and coworkers14 described
the reverse pivot shift test as taking the knee from 90 to 0
with a valgus load applied. The leg is held in external rotation and a clunk is felt similar to that of a pivot shift for an
ACL injury. This test was examined by Cooper, in 1991, and
found to be positive in up to 35% of normal knees.43 Finally,
Ferrari and colleagues44 described a standing apprehension
test. With the patient standing and the knee slightly flexed,
the examiner places his thumbs on the anterolateral aspect of
the lateral femoral condyle and applies a posteriorly directed
force. The patient feels a sensation of giving way as movement of the condyle relative to the plateau is experienced.
Instrumented devices may also allow for objective measures of instability. The KT-2000 device is available for
this purpose. The Lars Rotational Laxiometer (Lars Inc.,
Dijon, France) is another device capable of yielding objective values of instability. Normal side-to-side variation is,
approximately, 4.4 at 90 of knee flexion and 5.5 at 30
of flexion.45

Radiographic Evaluation
Radiographic evaluation may also provide valuable information that should direct concern to a posterior or posterolateral
injury. On plain radiography, the position of the knee may
reflect a potential injury. Posterior sag may be visible or the
overall alignment may be disrupted. Obvious dislocation and
subluxations should be observable immediately. Avulsion
fractures are not uncommon and may indicate ligamentous
injury. Tibial spine or posterior tibial avulsions may indicate

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cruciate compromise. Avulsion of Gerdys tubercle may

direct one to potential posterolateral instability. An arcuate
fracture, or avulsion of the fibular head, should cause the
physician to suspect a potential lateral or posterolateral injury. Compression injuries may also be visible, particularly
on the tibial plateau. Segond fractures are commonly thought
to indicate ACL injury; however, due to the strong lateral
capsular insertions, they may also demonstrate posterolateral injury. A widening of the lateral joint space may also
be visible.1 Stress views should be obtained to evaluate for
dynamic injury.
Magnetic resonance imaging (MRI) is particularly
helpful in the diagnosis of ligamentous injuries about the
knee. However, the standard protocols are not ideal for the
evaluation of the posterolateral corner. LaPrade and associates46 described specific protocols for posterolateral corner
evaluation, and Yu and coworkers47 suggested T2-weighted
coronal oblique views.
Posterolateral knee injuries often will show bone edema
on the anteromedial aspect of the lateral femoral condyle.48
This pattern of edema was present in all cases of combined
PCL and posterolateral corner knee injuries in a study by
Ross and colleagues.48 The size of the fibular styloid fracture
may also indicate the severity of injury. Given the various
anatomical ligament insertions, the particular area of the
fibular head that is avulsed may indicate which ligaments
are injured. Small avulsions with medial edema likely represent arcuate or PFL injury. Larger avulsions with diffuse
proximal fibular edema correlate with LCL and possibly
biceps femoris injuries.49
Juhng and associates50 performed an MRI study looking at
associated knee injuries in patients demonstrating the arcuate
sign on plain films. A remarkable number of injuries were
subsequently discovered on MRI following radiographic
observation of an avulsion fracture of the proximal fibula.
Of the total number of cases (18 knees; 17 patients), 89%
(16 cases) had a cruciate injury and 50% had both ACL
and PCL ruptures. Twenty-two percent to 28% had meniscal injuries, while 67% had posterolateral capsule injuries.
The popliteus was injured in 33% of patients. This study
illustrates the potential for intra-articular pathology when
a fibular avulsion fracture is appreciated. It is also notable
that the use of ultrasound for musculoskeletal diagnosis is
advancing rapidly in the identification of posterolateral corner structures, and while further in vivo research is needed,
its accuracy has been confirmed with surgical dissection.51

Grading
Various grading systems have been used to describe injuries
to the posterolateral corner of the knee. LCL laxity can be
referred to as grade I if there is 0 mm to 5 mm of opening
compared to the normal side. Grade II injuries demonstrate
6 mm to 10 mm of opening, while grade III injuries have
greater than 10 mm of opening and no firm endpoint. The
standard nomenclature of athletic injuries has also been ap-

plied to the posterolateral corner. Grade I represents minimal

tearing of a ligament with no abnormal motion. Grade II
injuries have partial tearing with slight or moderate abnormal
motion. Grade III injuries demonstrate complete tearing with
marked abnormal movement.2 The various grading systems
described make it difficult to compare studies.

Treatment
The treatment of posterolateral corner injury is difficult to
assess given the unknown natural history of such injuries. It
can be safe to assume that grade I and II injuries should be
managed nonoperatively. A brief period of immobilization in
full extension, lasting approximately 2 to 4 weeks, can be followed by progressive functional rehabilitation. Progressive
range of motion and strengthening exercises should begin
afterwards. As strength increases, specific sports programs
may ensue. Baker and coworkers2 showed a full return to preinjury level in 14 of 31 patients treated with immobilization
that was followed by quadriceps strengthening.
When determining operative indications, one must first
assess the potential for healing an injury. Using a rabbit
model, LaPrade and colleagues52 examined the potential for
healing complete ruptures of the LCL and popliteus tendon.
After 12 weeks, a gross and biomechanical analysis demonstrated that only one LCL injury healed and no popliteus
tendons healed. This illustrates the lack of potential for
healing of grade III posterolateral corner injuries.
Clinically, Kannus53 has also shown that complete tears
have poor functional outcomes. Gait abnormalities and
increases in articular pressure have led many surgeons to
suggest operative intervention for these injuries. The indications for surgery include symptomatic instability with
functional limitations, supplemented by objective physical
findings. These may include a 2+ varus opening at 30 of
knee flexion, a positive external rotation recurvatum test, a
posterolateral external rotation test, and an increased tibial
external rotation test, such as demonstrated by the dial
test.54
The treatment of acute injuries, traditionally, has demonstrated improved results compared to that of chronic injuries.
This discrepancy of outcome is mostly likely influenced by
attempts at repair rather than reconstruction. Principles of
management include the concurrent treatment of cruciate
injuries55 and assessing the overall mechanical alignment
of the knee. Any varus deformity about the knee will place
undue stress on the posterolateral aspect of the knee and
increase the potential for failure of repair or reconstruction56
If a varus deformity exists, it should be addressed prior to
or concurrently with that of the posterolateral corner.57
Treatment may be divided into specific categories or may
include a combination of more than one method. Direct
repair of the injured structures is the first issue to be addressed. This may or may not include advancement of these
structures or augmentation with either autograft or allograft.
Reconstruction can be anatomic or nonanatomic. The distinct

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ligaments may be reconstructed or a nonanatomic construct

may be fashioned to provide the same function as the native structures. Reconstruction may use a variety of grafts,
including native bone-patellar tendon-bone, hamstrings, or
the central aspect of the biceps femoris tendon. Achilles,
bone-patellar-bone graft, or alternate tendinous allografts
may also be utilized.
A posterolateral reconstruction is usually done through
a lateral approach to the knee. The incision begins on the
distal lateral thigh and extends toward the region between
Gerdys tubercle and the fibular head. The fascial interval is
between the iliotibial band and the short head of the biceps
femoris. Terry and LaPrade described a similar skin incision
but with the use of three separate fascial incisions and one
capsular incision.58
The results of direct repair are best when treating avulsions. The knee is kept in about 60 of flexion with slight
internal rotation of the tibia. The results of Baker and associates,2 with direct repair, showed 85% good subjective
results and 77% good objective results. Eighty-five percent
of patients returned to their pre-injury level of play; 15%
did not.
The issue of timing has to be discussed when dealing with
repair of these injuries. Better results with acute over chronic
surgical intervention has been demonstrated by Baker and
coworkers34 and Hughston and colleagues.4 Intervention
within the first 3 weeks has been suggested.59 As chronic
injuries have a higher failure rate with repair, reconstruction
has been suggested as the more effective treatment.2
Augmentation can be used when there is attenuated tissue
or the primary repair is tenuous. Slips of the iliotibial band
(ITB) or biceps can be used to augment the popliteofibular
or popliteus ligaments, respectively.56,60
Advancements of the entire posterolateral complex have
been described, both proximal and distal. The complex is
moved proximally in line with the LCL, fixed to a point
anterior to the center of rotation of the knee, and tightened
in 30 of flexion with the tibia in neutral.4 The results of this
procedure have been mixed. DeLee and associates, in 1993,
demonstrated 73% good results at 7.5 years with no evidence
of degenerative joint disease.1 Hughston and Jacobsen,4 in a
study of 96 patients using distal anterior advancement, had
85% good objective results, 78% good subjective results,
and 80% good functional results. Noyes and Barber-Westin59
performed proximal posterolateral advancement, in combination with reconstruction of one or both cruciate ligaments.
In addition, they fixed the complex to near anatomic origin
at 30 of flexion. Sixty-four percent of patients were fully
functional, 27% were partially functional, and 9% were
nonfunctional.
Reconstruction techniques use either autograft or allograft. Local autograft donor sites include the central third
of the biceps tendon, the iliotibial band, hamstring tendons,
and bone-patellar tendon-bone complex. The reconstruction
may be either an attempt to anatomically recreate the relevant

111

structures or to recreate the function of the posterolateral

corner with alternate structures or techniques.61,62
Nonanatomic techniques include the biceps tenodesis
and the posterolateral sling procedure.63 With the biceps
tenodesis technique, the biceps tendon is fastened down to
the lateral femoral condyle to a point 1 cm anterior to the
epicondyle. The fibular insertion and alternate insertions of
the biceps tendon are maintained. Clancy and colleagues64
have demonstrated 90% good results at 2 years with this
technique.
The posterolateral sling procedure recreates the function
of the posterolateral structures by passing a graft through an
anterior-posterior tunnel in the lateral aspect of the proximal
tibial plateau. The graft exits anterior to both the lateral gastrocnemius and popliteus and is secured to the LCL origin.
Eighty-seven percent improvement in symptoms has been
reported.39
Various anatomic reconstruction attempts have been
described and illustrated. The use of split grafts or multiple
grafts with two tunnels attempts to anatomically recreate the
function of the LCL, the popliteofibular ligament, and/or the
popliteus. Multiple investigators have described excellent
techniques for this type of reconstruction.56,59,61,64,66
Latimer and associates63 described a bone-patellar tendonbone construct for LCL insufficiency in which one aspect of
the graft is fixed to the isometric point of the lateral femoral
condyle; the other graft end is inserted into the fibular head.
The graft is tightened with a valgus load applied while the
knee is in 20 to 30 of flexion. Interference screws were
used to fix the graft. Of 10 patients, none had greater than
5 mm of varus or greater than 5 of external rotation at 30.
Five patients returned to their pre-injury level of function,
while four remained at one level of function lower.
Combination procedures, including reconstruction of the
LCL with plication of the posterolateral structures, have
been described as well. Veltri and Warren used a central slip
of biceps to reconstruct the LCL. Posterolateral plication
was added to prevent excessive external rotation.56 LCL
reconstruction with the Achilles tendon, combined with
posterolateral advancement or plication, yielded 76% good
or excellent results, with a 10% failure rate.65
Comparisons of the two- or three-ligament techniques
have been performed. Nao and coworkers67 examined a
reconstruction technique that recreated the LCL and popliteofibular ligaments to one that recreated the LCL, PFL
and the popliteus. They found that reconstruction of all three
ligaments actually led to abnormal kinematics, especially
with internal rotation during dynamic testing.
With all of the potential treatment options, it is difficult
to determine which yield the best results. This is particularly
true when dealing with a more acute injury, as simple repair
or plications are still an option. Stannard and colleagues68
performed an evaluation comparing acute primary repairs to
primary reconstructions with a two-tailed technique. Of the
57 patients available for follow-up at 24 to 59 months, 35

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patients underwent acute repair. Of the repair group, there

were 22 successes, with a failure rate of 37%. The primary
reconstruction group demonstrated 20 successes, with only
9% failures. The investigators concluded that primary reconstruction is a better option.
Biceps tenodesis has also been compared to reconstruction. The results of Kanamori and associates69 showed that
reconstructed knees had no difference in tibial external rotation from intact knees, while those that underwent biceps
tenodesis had an increase in external rotation of 5.7. They
suggested that reconstruction reproduces the native knee
better than biceps tenodesis.
When examining posterolateral injuries with PCL
reconstruction, the results are improved if posterolateral
reconstruction is also performed. Knee kinematics are restored to near normal, and forces in the PCL reconstruction
are decreased.51 In addition, external rotation is restored
to near normal kinematic patterns.70 These good results
are not the rule. Wang and coworkers71 showed that for
PCL reconstruction combined with LCL advancement and
popliteus reconstruction, there was only a 68% satisfactory
result; 40% were noted as good, 28% excellent. There was
a 32% unsatisfactory rate, with only 44% of knees achieving complete ligamentous stability. Even more alarming is
the 44% incidence of degenerative changes, given that the
follow-up period was only 2 years to 5 years.
These surgeries are not without complications. Peroneal
nerve injuries, vascular injuries, and hamstring weakness
have been described. Infection, hardware irritation, arthrofibrosis, and stiffness may also occur. It is important for the
surgeon to be aware of potential peroneal nerve displacement. In one study, 16 of 18 patients with biceps avulsions
or avulsion fractures of the fibula demonstrated anterior
displacement of the peroneal nerve.72 In that study, the 34
patients with either proximal avulsions, midsubstance disruptions, or distal avulsions without fibular head involvement
showed no displacement of the peroneal nerve.

will help as well although specifically oriented views may

be necessary. The treatment of posterolateral corner injuries
often requires surgical intervention, particularly if there is a
combined ligamentous injury pattern. Recent studies have
demonstrated that primary reconstruction may yield better
results than repair. Individual clinical scenarios can be evaluated better with knowledge of the various techniques as well
as the recent comparative outcomes of those techniques.

References
1.

2.

3.

4.

5.

6.
7.
8.

9.
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11.

Rehabilitation
Although rehabilitation programs vary, most recommend
partial or non-weightbearing in extension for a period of up
to 4 weeks in a Bledsoe-type brace. Isometric quadriceps
exercises and range of motion are begun as soon as pain
permits. Patients are protected from any varus or external
rotation stress for a minimum of 2 months. Hamstring
strengthening is started after 3 months. Many patients will
require 9 months to 12 months of supervised therapy.

12.

13.

14.

Summary
Injuries to the posterolateral corner of the knee remain a difficult entity. The diagnosis requires a high degree of suspicion
as well as a thorough knowledge of the functional anatomy
of the knee and lower extremity. A detailed clinical examination in various degrees of knee flexion with comparison to
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