Acute PLC Management



1.  Isolated LCL injury

2.  Isolated Posterolateral Corner

3.  PCL + posterolateral corner

4.  ACL / posterolateral corner

5.  ACL / PLC / posterolateral corner

Repair versus Reconstruction


Levy et al. Am J Sports Med 2010

- failure in 4/10 knees treated with acute primary repair

- failure in 1/18 knees treated with reconstruction


Stannard et al. Am J Sports Med 2005

- acute primary repair on 35 patients, with 37% failure at 2 years

- primary reconstruction on 22 patients, with 9% failure at 2 years


Geeslin et al. Am J Sports Med 2016

- systematic review of treatment of acute posterolateral corner injuries

- 134 patients

- overall, 81% achieved objective stability

- repair with staged reconstruction resulted in 38% failures

- early reconstruction +/- repair resulted in 9% failures


Takeaway message

- the ligaments stretch before avulsing

- reasonably strong evidence that repair only more likely to fail

- reasonable evidence that repair followed by other ligament reconstruction more likely to fail





- femoral avulsion of popliteus / LCL

- fibular head avulsion of LCL / biceps femoris

- bony avulsion of LCL / biceps femoris



- need to do 2 - 3 weeks post injury to identify structures


Fibula head bony avulsion ORIF

Acute fixation of bony avulsion of fibula with screw



- anchor repair of femoral or fibular avulsion

- screw fixation of bony avulsion into tibia

- typically back up with reconstruction


Surgical approach to posterolateral corner




Supine with sandbag under buttock

- knee flexed 90°

- radiolucent table





- Gerdy's tubercle and midpoint femoral condyles

- long curved incision centred over Gerdy's tubercle

- clear subcutaneous fascia down to ITB


3 fascial windows


1. Posterior to Biceps femoris


Posterior window CPNPosterior window CPN


Find and protect CPN 

- identify out of zone of injury proximally

- posterior to biceps femoris

- open fascia

- identify nerve in back of fat

- release

- dissect down to fibular neck

- contained in fibular tunnel (peroneus longus muscle)

- has connective tisse securing to fibular neck which must be released

- release down into anterior compartment

- identify and protect with vessiloop


2.  Between biceps and ITB


Middle window lateral knee


Elevate posterior border to ITB

- identifies the fibular head

- LCL fibular insertion

- posterolateral window for exposing tibia


3.  Bisect ITB


Three windows lateral knee


Dissect onto epicondyle

- femoral insertion LCL

- femoral insertion popliteus


Identify femoral insertion of LCL and popliteus


Can tag LCL on fibular head

- pulling on it will identify femoral insertion

- insertion is 1.4 mm proximal  and 3 mm posterior to lateral epicondyle


Open popliteal sulcus

- follow popliteal tendon into insertion at anterior 1/5 of sulcus

- this is intra-articular

- distal and anterior to LCL insertion

- 18.5 mm from LCL insertion


PLC Dissection 1PLC Dissection 2


Prepare fibular for LCL reconstruction


Window posterior to ITB

- preserve insertion of long head of biceps femoris

- protect CPN

- open long head of biceps bursa to identify LCL insertion


LCL reconstruction

- release anterior compartment muscles (peroneus longus) from anterior fibular head and neck

- clear posterior fibular head and neck (popliteus muscle)


Posterolateral corner (LCL + popliteus +/- popliteofibular)




1.  Laprade technique (allograft or autograft) (anatomic - fibular and tibia attachments)

2.  Arciero technique (fibular only)

3.  Larson loop (fibula sling)




Extremely mixed groups of patients, so conclusions difficult to make


Treme et al. Orthop J Sports Med 2019

- biomechanical comparison of LaPrade anatomical reconstruction and Arciero technique

- no significant difference in varus or external rotation stability for either


1a.  LaPrade posterolateral corner reconstruction (allograft technique)


LaPrade surgical technique PDF


LaPrade vumedi



- reconstructs LCL / popliteus / popliteofibula




Achilles allograft split in two

- 8 x 20 mm bone blocks

- LCL - tendon needs to pass through a 7 mm fibular tunnel

- popliteus - tendon needs to pass through a 7 or 8 mm tunnel


Femoral Tunnels


Laprade LCL and popliteus insertions

















LCL femoral tunnel

- split ITB to identify the femoral insertion

- develop windown posterior to ITB to identify insertion onto fibular head

- can place suture into LCL at fibular head, tugging on it will identify femoral inseriont

- insertion is 1.4 mm proximal to epicondyle and 3 mm posterior

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw


Popliteus femoral tunnel

- use split ITB window

- follow popliteus sulcus anteriorly

- femoral tunnel is 18.5 mm anterior and distal from LCL

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw


PLC Popliteus and LCL Femoral Drill HolesPLC Allograft Femoral Screw

PLC Pass Popliteus Tendon deep to fascia


Tibial / Fibular tunnels


Fibular tunnel for LCL

- insertion of LCL is 8 mm from anterior fibular and 25 mm distal to fibula styloid

- tunnel will pass anterolateral in proximal fibular to posteromedial

- ensure that there is sufficient superior bone in fibular head

- if blow out fibular head will not be able to secure LCL

- place posterior retractor

- drill 7 tunnel protecting the CPN


Fibular tunnel 1Fibula tunnel 2


Popliteus tibial tunnel

- anterior entry point is distal and medial to gerdy's tubercle, below tibial plateau

- create posterior window

- anterior to lateral head of gastrocnemius, posterior to knee capsule, above LHB

- insert retractor under lateral head of gastrocnemius to protect vascular structures

- identify and ligate the lateral inferior geniculate artery

- indentify with a finger the proximal tibio-fibular joint

- the posterior tunnel must exit medial to this joint, below tibial plateau

- at approximate site of the popliteus musculotendinous junction

- pass beath pin anterior to posterior

- drill to 9 mm


Popliteus tunnel 1Popliteus tunnel 2


Pass and secure grafts


LCL graft

- pass under IT band

- pass front to back through fibular tunnel

- secure with front to back 7 x 20 mm soft tissue screw

- foot at 30o of flexion, neutral rotation, valgus force

- can pass second limb through popliteus tibial tunnel to reconstruct popliteofibular ligament

- can also secure second limb back onto itself

- or secure second limb onto femur with screw and soft tissue washer


PLC LCL Allograft Deep to Fascia


Popliteus graft

- pass under IT band and the LCL

- pass back to front through tibial tunnel

- secure with front to back soft tissue screw 9 x 25 - 30 mm

- foot at 70o of flexion, neutral rotation


ACL + posterolateral corner reconstruction 1ACL + Posterolateral corner reconstruction 2

ACL + Laprade reconstruction of LCL and popliteus

1b. Laprade posterolateral corner reconstruction (hamstring autograft technique)


LaPrade surgical technique PDF


2. Arciero posterolateral corner reconstruction



- femoral tunnels in anatomic location of LCL and popliteus

- standard trans-fibular tunnel

- reconstructs LCL and popliteus ligament



- popliteus tunnel is blind

- LCL tunnel is drilled through femoral condyles


Arciero surgical technique PDF


Arciero Vumedi


3. Modified Larson loop



- fibular sling

- single femoral tunnel

- standard transfibular tunnel

- dock both limbs into femoral tunnel



- single femoral tunnel at eipcondyle

- standard anterolateral to posteromedial 7 mm fibula tunnel

- pass graft through fibula

- posterior limb passed deep to ITB and long head of biceps

- anterior limb passed deep to ITB

- secure both limbs in single femoral tunnel


LCL graft passed through fibulaLCL Recon 2


LCL ReconstructionLCL Reconstruction Lateral


ACL + Posterolateral corner




Convergence of ACL tunnel and femoral tunnels of popliteus / LCL


Drill anterior to avoid more posterior ACL femoral tunnel

Avoid proximal drilling of LCL tunnel, as will approach ACL femoral tunnel


Moatshe et al. Am J Sports Med 2017

- avoiding tunnel convergence

- aim LCL and popliteus tunnel anteriorly 35o


Gelber et al. Arthroscopy 2013

- CT analyis of PLC tunnels in setting of ACL

- popliteus tunnel: drill at 30o proximal and 30o anterior

- LCL tunnel: drill at 30o anterior, but 0o proximal


ACL and posterolateral cornerACL and Posterolateral corner


Graft tensioning sequence


Evidence unclear


1. ACL

2. LCL

3. Popliteus