n Case Report

All-arthroscopic Anatomic Repair of an

abstract
Full article available online at Healio.com/Orthopedics. Search: 20120525-46

Multiple ligament–injured knees are a heterogeneous group of knee injuries that lack
a clear consensus on optimal treatment. Current areas of controversy include opti-
mal timing of surgery, ligamentous repair vs reconstruction, and combined vs staged
procedures. In addition, multiple open, arthroscopic, and arthroscopic-assisted tech-
niques exist for repair and reconstruction of the injured stabilizers of the knee.

Many open posterolateral corner reconstruction techniques have been described, and Figure: Arthroscopic view of the lateral gutter
this article represents the first description of an arthroscopic technique for repair of an showing the avulsion of the popliteus tendon from
avulsed popliteus tendon. This was performed with a standard anterolateral portal in its footprint.
addition to anterior and posterior superolateral portals. Nonabsorbable sutures were
passed through the avulsed popliteus tendon in an outside-in technique using a suture
shuttle. The nonabsorbable sutures were threaded though a tibial Beath pin, which was
then passed through the prepared popliteus footprint and brought out medially. The
final position of the popliteus was confirmed arthroscopically, and the sutures were
tied medially over a screw post with a washer.

Arthroscopic popliteus repair has many possible advantages. Because the popliteus
tendon insertion is intracapsular, open repair necessitates a capsulotomy, with the
potential for complications such as postoperative wound drainage, intra-articular sinus
formation, infection, and stiffness. Arthroscopic repair may avoid these complications.
The current case was performed in conjunction with an open but extracapsular pos-
terolateral corner repair. Further experience with this technique is required to deter-
mine its safety and efficacy.

Drs Matthew and Scott are from the Department of Orthopaedics, Brigham and Women’s Hospital,
Boston, Massachusetts.
Drs Matthew and Scott have no relevant financial relationships to disclose.
Correspondence should be addressed to: Matthew J. Salzler, MD, Department of Orthopaedics,
Brigham and Women’s Hospital, ASBII, 75 Francis St, Boston, MA 02115 (msalzler@partners.org).
doi: 10.3928/01477447-20120525-46

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M
anagement of the multiple demonstrating 10° of external rotation sutures (DePuy, Raynham, Massachusetts)
ligament–injured knee has compared with the unaffected side; his were passed through the popliteus tendon
long been a challenge for or- posterior drawer had a firm endpoint. via the 2 superolateral working portals using
thopedic surgeons and is a popular topic After examination, the patient was placed an outside-in technique with a suture shuttle
in sports medicine.1 Posterolateral corner in the supine position on the operating and 0 PDS suture (Ethicon, Inc, Somerville,
structures have been shown to biomechan- table with his affected knee flexed to 90°. New Jersey) (Figure 3B, C).14 A tibial Beath
ically and clinically play an important role A tourniquet was applied to the thigh, pin was then placed in the knee through the
in the treatment outcomes of the multiple and the patient was prepped and sterilely anterior superolateral portal under direct
ligament–injured knee.2-6 These combined draped in the usual fashion. arthroscopic view and into the center of the
injuries can lead to either subtle or gross A routine diagnostic arthroscopy of the popliteus tendon footprint. Next, the poplit-
instability in 1 or more planes. In addition entire knee was performed with an evalu- eus tendon sutures were placed through the
to combined injuries, isolated injuries to ation of the lateral compartment as pre- eyelet of the Beath pin, which was passed
the posterolateral corner have been shown viously described in the literature.12 The through the knee from lateral to medial,
to significantly affect the forces across popliteus tendon was well visualized and aiming for the medial epicondyle (Figure 4).
the anterior and posterior cruciate liga- avulsed off its footprint (Figure 1). The At this point, attention was turned to
ments.7,8 Furthermore, when combined popliteus tendon was intact but avulsed, other intra- or extra-articular knee pathol-
with posterior cruciate ligament recon- not retracted, and had adequate substance ogies, such as concomitant ligamentous
struction, repairing the posterolateral cor- and length for repair. With the arthroscope
ner can decrease posterior cruciate liga- in the standard anterolateral portal, poste-
ment graft forces and increase varus and rior superolateral and anterior superolat-
external rotational stability.9-11 Numerous eral working portals were created safely
open procedures have been described to as working portals.13 These portals were
reconstruct the posterolateral corner of made with the knee in 90° of flexion; they
the knee. This article represents the first were placed slightly proximal and distal to
description of an all-arthroscopic primary the lateral collateral ligament and through
repair of a femoral popliteal avulsion in a the iliotibial band to safely access the pop-
patient with multiple ligament instability. liteus tendon and its footprint (Figure 2).
Once the working portals were estab-
Case Report lished, a burr was inserted through the an- 1
A 46-year-old helmeted motorcyclist terior superolateral portal, and the popliteus Figure 1: Arthroscopic view of the lateral gutter
was struck by a motorist and sustained footprint was burred down to a corticocan- showing the avulsion of the popliteus tendon from
multiple injuries, including an intraparen- cellous base (Figure 3A). Two #2 Orthocord its footprint.
chymal hemorrhage, an L1 burst fracture
without neurologic involvement, a left
distal humerus fracture, and a right knee
dislocation. His intraparenchymal hemor-
rhage and L1 burst fracture were treated
nonoperatively, and he underwent open
reduction and internal fixation of his dis-
tal humerus fracture. His right lower ex-
tremity was neurovascularly intact, and
magnetic resonance imaging of the knee
demonstrated ruptures or avulsions of his
anterior cruciate ligament, medial and
lateral collateral ligaments, popliteus ten-
don, and posterolateral arcuate complex.
While under general anesthesia, the 2A 2B
patient was examined and found to have
Figure 2: Lateral illustration of a right knee demonstrating correct placement of the lateral working portals
a grade 2B Lachman’s test, a positive with the location of the popliteus tendon footprint (A). Arthroscopic image showing the creation of the
posterolateral drawer test, and a dial test anterior superolateral working portal (B).

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3A 3B 3C
Figure 3: Arthroscopic image of the lateral femoral condyle at the popliteus tendon insertion showing the avulsed footprint of the popliteus insertion (A). Ar-
throscopic image (B) and stepwise illustration (C) showing the suturing of the popliteus tendon using an outside-in technique.

with a washer on the medial side of the volves an understanding of the concomi-
knee via a series of half hitches that were tant knee injuries. Popliteus tendon inju-
buried subcutaneously (Figure 4). After ries often occur in conjunction with inju-
fixation, the lateral gutter was again ex- ries to the other posterolateral structures,
amined to ensure that the popliteal recess such as the lateral collateral ligament and
was now closed off without the ability to arcuate ligament complex, as well as with
easily drive through the recess. injuries to the anterior and posterior cru-
The postoperative protocol was de- ciate ligaments and medial and lateral
termined based on the other repairs per- menisci. These concomitant injuries must
formed during the procedure. The pa- not be overlooked because they play a sig-
tient was kept partial weight bearing for nificant role in determining the treatment
6 weeks with an unlocked hinged knee plan.16
immobilizer. Active and passive range of To the authors’ knowledge, this is the
motion exercises and isometric quadri- first report of all-arthroscopic repair of an
ceps exercises were started 2 weeks post- avulsed popliteus tendon. Recently, an all-
operatively. After 6 weeks, he progressed arthroscopic technique for a posterolateral
to weight bearing as tolerated with a sling reconstruction of the popliteus ten-
4 short-hinged knee brace. Four months don was described.17 The technique was
Figure 4: Stepwise illustration of Beath pin inser- postoperatively, he transitioned to a light reported in conjunction with a single-
tion showing reattachment of the popliteus tendon knee sleeve. One year postoperatively, the bundle posterior cruciate ligament recon-
with screw fixation. patient returned to work and full activities struction and differs significantly from the
of daily living. His knee was stable, with current technique, an anatomic repair. The
injuries. An arthroscopic-assisted ACL re- 0° to 135° of flexion, good strength, and all-arthroscopic repair technique allows
construction and open medial and lateral good patellar mobility. for more accurate tensioning and does not
collateral and posterolateral arcuate com- require use of an allograft. However, be-
plex reconstructions were performed. If Discussion cause the current technique is anatomic,
surgical correction of a medial collateral The diagnosis of a popliteus tendon in- sufficient length and quality of the avulsed
ligament is to be performed, the authors jury can be made either by using magnetic popliteus tendon must exist to replace a
recommend that this be completed prior resonance imaging or arthroscopically by healthy tendon on its footprint with mini-
to tying down the passed sutures from the examining the footprint and driving the mal tension.
popliteus tendon because they may need to arthroscope between the popliteal tendon The benefits of all-arthroscopic poplit-
be manipulated during the medial repair. and lateral femoral condyle, known as the eus repair are many. It avoids the morbidi-
When ready, the passed popliteus tendon lateral gutter drive-through.15 Once the ties associated with an open technique.
sutures were tied down over a screw post diagnosis is made, surgical planning in- Specifically, because the insertion of the

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popliteus is intra-articular, an open repair dications, and outcomes compared with 8. LaPrade RF, Muench C, Wentorf F, Lewis JL.
The effect of injury to the posterolateral struc-
also necessitates a lateral capsulotomy. open or nonoperative treatment. tures of the knee on force in a posterior cruci-
An arthroscopic repair that obviates the ate ligament graft: a biomechanical study. Am
J Sports Med. 2002; 30(2):233-238.
need for a capsulotomy may be able to Conclusion
9. Markolf KL, Graves BR, Sigward SM, Jack-
decrease the risk of postoperative wound All-arthroscopic repair of an avulsed
son SR, McAllister DR. Popliteus bypass and
drainage, intra-articular sinus formation, popliteus tendon has multiple uses. It can popliteofibular ligament reconstructions re-
infection, and stiffness that may accompa- be performed in the case of an isolated duce posterior tibial translations and forces in
a posterior cruciate ligament graft. Arthros-
ny a capsulotomy. The potential for avoid- avulsion or when the popliteus tendon is copy. 2007; 23(5):482-487.
ing a lateral knee incision potentially de- the only injured posterolateral structure 10. Markolf KL, Graves BR, Sigward SM, Jackson
creases the risk of peroneal nerve injury. with a mild rotatory instability. This tech- SR, McAllister DR. Effects of posterolateral
Furthermore, arthroscopic visualization nique may, in some cases, be able to elim- reconstructions on external tibial rotation and
forces in a posterior cruciate ligament graft. J
of the portal creation and Beath pin place- inate the need for an open incision and Bone Joint Surg Am. 2007; 89:2351-2358.
ment allows the surgeon to safely avoid may decrease the risk of complications 11. Markolf KL, Graves BR, Sigward SM, Jack-
injuring the geniculate arteries.18 Finally, associated with capsulotomy in open pro- son SR, McAllister DR. How well do ana-
tomical reconstructions of the posterolateral
because of the popliteus footprint’s close cedures.
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