Peroneus Longus Tendon Graft to Reconstruct the Posterolateral Corner of the Knee^[*]

Abstract

The posterolateral corner is critical to knee stability. Neglected injuries have a direct impact on the prognosis due to residual instability, chronic pain, deformities, and failure to repair other structures. Several techniques are used to reconstruct the posterolateral corner, often with autologous ischiotibial grafts or homologous grafts. An option little used for knee ligament reconstructions is the peroneus longus tendon graft. Although reported as a good alternative for anterior cruciate ligament reconstruction, we found no case using a peroneus longus tendon graft for posterolateral corner reconstruction. Here, we describe the case of a patient who underwent a non-anatomical reconstruction of the posterolateral corner using a peroneus longus tendon graft.

The patient underwent surgical procedures for ligament reconstruction and correction of the deformity caused by a failed graft, but his knee remained unstable. During the preoperative planning, it was decided to reconstruct the posterolateral corner with an ipsilateral peroneus longus tendon graft.

Studies have shown that the peroneus longus tendon graft does not increase ankle morbidity, and that its length and diameter favor ligament reconstruction. Thus, the present article highlights the importance of the proper diagnosis of ligament injuries in the acute phase, and describes a new technique for posterolateral corner reconstruction that must be included in the surgeon's body of knowledge, increasing the amount of technical options.

Keywords

autograft - joint instability - anterior cruciate ligament injuries - anterior cruciate ligament reconstruction

Introduction

The posterolateral corner (PLC) consists of three primary structures: the peroneal collateral ligament, the popliteal tendon, and the popliteofibular ligament. It limits external rotation, varus movement, and posterior translation. A neglected PLC injury directly impacts the prognosis because it leads to residual instability, chronic pain, deformities, and failure to repair other structures.[1] Several techniques are used for PLC reconstruction, including autologous ischiotibial grafts (ITGs) or homologous grafts.[2] A little-used option for knee ligament reconstructions is the peroneus longus tendon graft (PLTG). Its use for the reconstruction of the anterior cruciate ligament (ACL) is reported by some studies, including the one published in 2008 by Kerimoğlu et al.[3] analyzing outcomes from 29 patients. Although this graft has been used for some years, we found no case of PLC reconstruction with it in the literature. Here, we describe the case of a patient who underwent a non-anatomical PLC reconstruction using PLTG and his postoperative follow-up.

Case Report

A 33-year-old male patient with pain and instability in the left knee. An ACL reconstruction was performed using an ipsilateral ITG. Due to graft failure and the development of varus deformity after one year, an ACL reconstruction review with a contralateral ITG and tibial valgus osteotomy was performed. Ten weeks later, the patient still reported pain and instability. A physical examination revealed a varus deformity in the left knee ([Fig. 1]), positive varus stress with the knee at 30° and 0° of flexion, positive dial test at 30°, positive anterior drawer test in internal rotation, and positive reverse pivot shift. Recent imaging scans demonstrated previous manipulation of the left proximal tibia with a medial opening wedge, plate, and screws, with signs of bone healing ([Fig. 2]). Magnetic resonance imaging showed signs of a neglected injury in the PLC. During the preoperative planning, a PLTG was chosen for PLC reconstruction using a non-anatomical technique.

Fig. 1 Panoramic clinical image of the lower limbs during the preoperative evaluation.

Fig. 2 Preoperative anteroposterior and lateral radiographs of the left knee.

With the patient in supine position, a 2-cm incision posterior to the lateral malleolus was made ipsilaterally to the ligament injury. The peroneus brevis and longus tendons were dissected, identified, and isolated ([Fig. 3]). Both tendons were sutured, and the peroneus longus tendon was repaired and sectioned proximally to the suture. The tendon was then removed using a tenotome ([Fig. 4]). A non-anatomical PLC reconstruction was performed under direct visualization using a lateral approach ([Fig. 5]). Following reconstruction, knee stability was satisfactory. At the postoperative follow-up, the patient did not report pain in the left ankle, with preserved range of motion.

Fig. 3 Intraoperative image. A 2-cm incision posterior to the lateral malleolus, ipsilateral to the ligament injury. Identification and isolation of the peroneus longus and brevis tendons.

Fig. 4 Intraoperative image. Graft harvest from the peroneus longus tendon.

Fig. 5 Non-anatomical posterolateral corner reconstruction under direct visualization in a lateral approach.

Discussion

Ischiotibial tendons are usually the first choice for the reconstruction of knee ligaments. In multiligament lesions, this graft may not be enough to provide proper knee stability, since these techniques require a large volume of graft for anatomical recovery. Thus, other grafts are used to add length and diameter. Some of them are well established, such as autologous grafts from the quadriceps and patellar tendons, or even homologous grafts available in tissue banks. However, in the clinical practice, we observed that grafts from the extensor mechanism are not suitable for some techniques and can result in drawbacks, including pain at the harvest site and limitations in daily activities, especially in patients who need to perform activities while kneeling down. Another option would be a homologous graft, which presents greater flexibility in terms of shape and configuration for the performance of different techniques. However, their use is limited due to the high cost and unavailability in some services; in addition, these grafts are prone to immunological rejection and disease transmission.

In this context, the peroneus longus tendon emerged as an alternative graft for ACL reconstruction. Patients reportedly present anterior knee pain and hypotrophy of the thigh muscles after ACL reconstructions with grafts from the extensor mechanism.[4] The peroneus longus muscle tendon is in a superficial anatomical position that facilitates surgical access; in addition, since it has a good length, it is versatile, and can be used in various ligament reconstruction techniques. However, the lack of the peroneus longus tendon has potential consequences to the ankle, including its stability and biomechanics. Studies[4] [5] [6] [7] indicate that patients undergoing peroneus longus graft harvest do not present significant changes in muscle strength, range of motion, loading and gait compared to the non-operated side, with no pain complaints or diminished physical activities. Thus, the literature[3] [4] [5] [7] describes that the use of autologous grafts from the peroneus longus ipsilateral to the ligament injury is safe, with a low morbidity rate, one of the reasons why it was chosen for our patient. Despite being widely reported as a good option for ACL reconstruction, we found no case in the literature using the same graft for PLC reconstruction. In a patient with a neglected PLC injury, who had already undergone bilateral ischiotibial graft harvest and with no available graft in tissue banks, the choice for a graft with minimal complications and a simplified surgical access, avoiding excessive surgical manipulation, was deemed the most appropriate.

The use of a peroneus longus tendon graft for knee ligament reconstruction is a good option, and it must be included at the surgeon's body of knowledge, increasing the amount of technical options. A proper physical examination of all knee structures is critical to avoid missing ligament injuries, such as those to the PLC, which potentially lead to treatment failures.

Conflito de Interesses

Os autores declaram não haver conflito de interesses.

Financial Support

There was no financial support from public, commercial, or non-profit sources.

^* Study developed at Faculdade de Ciências Médicas, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.

• Referências

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Publication History

Received: 09 September 2020

Accepted: 30 November 2020

Article published online:
20 December 2021