Full text of DOI:10.1007/s00167-002-0288-9

Knee Surg, Sports Traumatol, Arthrosc
2002) 10:266–273
(
KNEE
DOI 10.1007/s00167-002-0288-9
Paolo Aglietti
Roberto Buzzi
Daniele Lazzara
Posterior cruciate ligament reconstruction
with the quadriceps tendon
in chronic injuries
Abstract We reviewed 18 patients
knees) operated on because of
chronic PCL insufficiency. Preopera- five of six knees with a lateral collat-
tively all the patients were severely
disabled and showed a posterior
side difference less than 2 mm in lat-
eral joint line opening was found in
Received: 5 March 2001
Accepted: 20 January 2002
Published online: 30 May 2002
(
©
Springer-Verlag 2002
eral ligament reconstruction. Poste-
rior tibial translation was similar in
drawer of 10 mm or more. A quadri- the knees with and those without col-
ceps tendon autograft was implanted lateral ligament reconstruction. Only
using an open technique, direct pos-
terior approach, and fixation to the
tibia. A free semitendinosus graft
was used to reconstruct the lateral
collateral ligament in six knees and
one patient complained of significant
pain and giving-way at follow-up.
Patellofemoral crepitation was pre-
sent in nine knees at follow-up al-
though it was symptomatic only in
the medial collateral ligament in two. one. The results of this series suggest
The patients were reviewed with a
mean follow-up of 3.5 years (range
that posterior cruciate ligament re-
construction using an autologous
quadriceps tendon is a valuable op-
2–5.5) using the IKDC form. Stabil-
ity was evaluated by stress radiogra- tion to reconstruct these severe in-
P. Aglietti (✉) · R. Buzzi · D. Lazzara
First Orthopedic Clinic
of the University of Florence,
Largo P. Palagi, 1,
phy using the Telos device. The
mean side-to-side difference in poste-
rior tibial displacement at 70° of knee Keywords Posterior cruciate
flexion at follow-up was 4.8 mm; the ligament · Quadriceps tendon
side-to-side difference was less than
5 mm in 77% of cases. A side-to-
juries.
50139 Florence, Italy
autograft · Posterior tibial approach ·
Direct tibial fixation
Tel.: +39-055-416901,
Fax: +39-055-4224063
tures. Symptomatic chronic PCL injuries frequently pre-
sent with combined ligamentous injuries and often require
surgical reconstruction.
Introduction
Surgical treatment of chronic posterior cruciate ligament
Reconstruction of a chronic PCL injury is less frequent
(PCL) injuries remains controversial. The indication to re- than reconstruction of an ACL. The surgical technique is
constructive procedures in acute isolated PCL injuries has demanding and risks several possible complications. The
been the subject of debate since several authors [10, 14, final result in terms of objective stability has been found
37, 41, 45] showed that good results can be achieved in to be less consistent than in ACL reconstructions [1, 30,
the short to medium term with conservative treatment. 34].
However, results tend to deteriorate with increasing fol-
Several autografts have been used for PCL reconstruc-
low-up due to the development of pain and degenerative tion, including the patellar tendon [8, 28, 32, 46], the
changes [5, 11, 27]. Acute combined PCL injuries require semitendinosus and gracilis [30, 38, 48], and the quadri-
surgical treatment to repair or reconstruct the PCL, the an- ceps tendon [7]. Achilles tendon and the patellar tendon
terior cruciate ligament (ACL), and the peripheral struc- allografts have also been used, mainly in the United States

267
[
13, 34, 35]. Numerous surgical techniques have been pro-
posed using open [8, 30] and arthroscopy-assisted [13, 21,
3
3
2, 35] procedures, single or double femoral tunnel [2,
1], and tibial tunnel [13, 21] or direct fixation [3, 9, 26]
of the graft on the tibial side.
In 1994 we started a prospective study on PCL recon-
struction in chronic injuries using the autologous quadri-
ceps tendon and a direct posterior approach to the tibia.
Combined ligamentous injuries were reconstructed at the
time of PCL reconstruction. The purpose of the present
study was to evaluate the results in a group of 18 knees
with a minimum follow-up of 2 years.
Material and methods
Patients
Between November 1994 and February 1998 we operated on 18 pa-
tients (18 knees) at the First Orthopedic Clinic of the University of
Florence because of chronic PCL injury. The study group included
1
1 men and 7 women; their average age at surgery was 26.7 years
(range 16–36). The PCL lesion was caused by a motor vehicle ac-
Fig.1 Measurement of posterior tibial displacement in the medial
and lateral compartment. The knee was flexed 70° and a posterior
force of 15 kg was applied to the tibial tuberosity. Lateral radiog-
raphy was performed. The medial and lateral femoral condyles and
corresponding plateaus were identified. A tangent to the tibial
plateau was drawn. Two lines perpendicular to the plateau line were
drawn, tangent to the most posterior aspect of each femoral condyle
and tibial plateau. The distance between these two lines was mea-
sured in millimeters and corrected according to the magnification
was drawn tangent to the tibial plateau. Two lines were drawn,
perpendicular to the tibial plateau line and tangent to the most pos-
terior aspect of the corresponding femoral condyle and tibial plateau.
Measurements
The preoperative and follow-up clinical evaluation was performed The distance between these two lines express the amount of poste-
according to the International Knee Documentation Committee rior tibial displacement (Fig.1). The difference in posterior dis-
(
IKDC) form [23]. Subjective assessment, symptoms (pain, placement between operated and normal knee were calculated for
swelling, and giving-way), range of motion and objective stability the medial and lateral compartment separately. A posterior tibial
are classified as normal, nearly normal, abnormal, and severely ab- displacement was also calculated averaging the displacements of
normal. The worst result achieved in each category determines the the medial and lateral plateaus. All the measurements were corrected
final result. A normal or nearly normal result is considered satis- according to the magnification.
factory. Preoperative and follow-up radiography included antero-
posterior 30×40 cm weight-bearing view, lateral view, and axial joint line opening in the knees which had a medial or a lateral collat-
view.
eral ligament reconstruction. The knee was stressed in varus or val-
The Telos device was employed to measure medial and lateral
Posterior tibial translation at follow-up was measured on stress gus applying a laterally or medially directed force of 15 kg (Fig.2).
radiographs obtained with the Telos device (SAMO, Bologna, The measurements of posterior tibial translation and joint line open-
Italy). The knee was flexed 70° as measured with two lines tangent ing were compared to the opposite normal knee. A side-to-side dif-
to the posterior femoral and tibial cortices. A posteriorly directed ference of 0–2 mm was considered normal, 3–5 nearly normal,
force of 15 kg was applied to the tibial tuberosity using a dy- 6–10 mm abnormal, and more than 10 mm severely abnormal [23].
namometer [35]. A lateral radiograph of the normal and injured
Preoperative posterior tibial displacement was 10 mm or more
knee was obtained using the image amplifier to achieve superim- in all the knees, as measured clinically. With the knee flexed at 90°
position of the femoral condyles. Posterior displacement was mea- the tibial plateaus were flush or posterior to the femoral condyles
sured separately in the medial and lateral compartments. The me- in each case. An associated ACL injury was present in four knees
dial femoral condyle was identified because of its convex distal as evidenced by an increased anterior tibial translation at the Lach-
contour and a flat terminal sulcus located anterior to the intercondy- man test and by a positive pivot shift, which was 2+ (jerk) in two
lar roof [43]. The lateral femoral condyle was distinguished by its knees and 1+ (glide) in two. Increased medial joint line opening
biconvex distal profile and a deeper triangularly shaped terminal was appreciated at the valgus stress test in four knees. It was 3–5 mm
sulcus located in the projection of the intercondylar roof. The me- in two knees and 6–8 mm in the other two. Increased lateral joint
dial tibial plateau was identified because of its concave profile and line opening was confirmed at the varus stress test in six knees,
squared off posterior contour. The lateral plateau was distinguished 3–5 mm in two cases, and 6–8 mm in four. Increased external tib-
by its convex or flat profile and sloping posterior contour. A line ial rotation (over 10°) at 30° and 90° was present in four knees.

268
Fig.2 Measurement of lateral
joint line opening. The knees
were flexed 10°. A laterally
directed force of 15 kg was
applied at the medial joint line
level. The minimum distance
between lateral femoral con-
dyle and tibial plateau was
measured in millimeters
The reverse pivot shift was 1+ (glide) in five knees and 2+ (jerk) of the cartilage. There were no cases with large areas of exposed
in ten.
subchondral bone representative of early osteoarthritis. The mobile
Preoperatively there were not cases with loss of motion. Four fragments of cartilage were removed.
patients had knee hyperextension (recurvatum) between 3° and 5°
A C-guide was used to introduce a K-wire in the medial
compared to the opposite normal knee. Patellofemoral crepitation femoral condyle. We aimed at a point located 5 mm from the ar-
was present preoperatively in seven knees, moderate in six, and ticular cartilage at the junction between roof and wall of the notch
symptomatic in one patient.
(1 o’clock position for the right knee). The K-wire was overdrilled
Statistical evaluation was performed using Fisher’s test. The with a 10–11 mm cannulated drill bit. The femoral tunnel was en-
minimum level of significance was set at P<0.05.
larged with a conical reamer to achieve interference fit with the
patellar bone block.
The quadriceps tendon graft was introduced with its ligamen-
tous end into the femoral tunnel. It was advanced until the trape-
zoidal bone block was firmly engaged and its tip was flush with
Surgical technique
The patient was placed supine on the operating table with the foot the wall of the notch. If the press fit fixation was not firm enough,
supported by a bolster and the knee in 70–80° of flexion. A pneu- an interference screw was added or the sutures were tied around a
matic tourniquet was used routinely. A medial parapatellar skin in- screw and washer on the medial aspect of the femoral metaphysis.
cision was made, beginning at the joint line level and proceeding
proximally up to 3 cm proximal to the base of the patella. A 10- to suction drain with a curved needle. With the knee in around 90° of
2-mm-wide full thickness strip of quadriceps tendon was sculp- flexion, the needle was inserted into the notch and pushed to exit from
The graft was pulled in the posteromedial compartment using a
1
tured with a trapezoidal bone block from the base of the patella. the posteromedial compartment. The sutures were recovered and
The bone block was 25 mm long and 2 mm wider distally than pulled posteriorly out of the skin. We have found that pulling the
proximally. Number 2 nonabsorbable Ethibond sutures (Pomezia, graft into the posteromedial compartment greatly enhances recovery
Italy) were placed through drill holes in the bone block. A Bunnel- of the graft from the posterior approach. The tourniquet was released,
type stitch was placed at the proximal end of the quadriceps ten- hemostasis was achieved. The wound was sutured as routinely.
don. The defect at base of the patella was filled with bone debris
collected while drilling the femoral tunnel. The defect in the quadri- was prepared again. A J incision was used [6] with the horizontal
ceps tendon was sutured. limb at the level of the popliteal crease and the vertical limb along
The patient was turned in the prone position and a sterile field
The joint was entered through a limited subvastus approach the medial margin of the gastrocnemius. The medial head of the
24]. This approach was advantageous since detachment of the gastrocnemius was displaced laterally. A posterior capsulotomy was
[
vastus medialis from the patella was avoided and simultaneously performed along the lateral margin of the medial femoral condyle.
access to the femoral metaphysis was gained to drill the femoral The incision was prolonged distally over the tibia until proximal to
tunnel. Exploration of the joint was performed. Meniscal and car- the inferomedial genicular vessels. Then the incision was turned
tilage pathology was recorded and treated as needed. There was a medially toward the posteromedial corner of the tibia (Fig.3). The
lesion of the lateral meniscus in two knees and of both menisci in graft was recovered from the posterior compartment. The posterior
one. Cartilage lesions were present in nine patients, involving the intercondylar area of the tibia was sharply exposed using a knife
medial femoral condyle (seven knees), medial tibial plateau (four and a periosteal elevator. The capsular flap was lifted from the
knees), lateral femoral condyle (four knees), and patella (six knees). posterior tibia until sufficient exposure was achieved. Retraction
These lesions were characterized by fissuring or deep fibrillation was enhanced by use of two Steinman pins inserted into the tibia.

269
Fig.3 Posterior capsulotomy.
The incision parallels the
lateral margin of the medial
femoral condyle and proceeds
distally to the upper limit of
the popliteus muscle. Here the
incision turns medially to the
posteromedial corner of the
tibia. The lower limb of the in-
cision runs parallel and proxi-
mal to the inferomedial genicu-
lar vessels
with the patient in the supine position. We harvested a free semi-
tendinosus (ST) graft through a prolonged anterior skin incision
using a tendon stripper. A 15-cm lateral skin incision was centered
on the Gerdy’s tubercle. The ileotibial band was split longitudi-
nally just anterior to the intermuscular septum to have access to the
lateral femoral epicondyle. The peroneal head was exposed pro-
tecting the peroneal nerve. A 4.5-mm tunnel was drilled in the pero-
neal head, starting in front of the styloid and exiting 2 cm distally
at the level of the neck. The graft was introduced into the tunnel
and sutured to itself and to the soft tissues around the proximal exit
of the peroneal tunnel (Fig.4). The ileotibial band was elevated
and the graft was rerouted deep to the ileotibial band to reach the
area of the lateral femoral epicondyle. The lateral epicondyle was
located by finger palpation. The remnants of the LCL can be also
used as a guide. A 2.5-mm K-wire was introduced into the lateral
femoral epicondyle. The ST graft is pulled tight around this wire.
The knee was flexed from 0° to 120° while maintaining the tibia
reduced underneath the femur. Length changes in the LCL graft
were observed. We aimed at a 3- to 4-mm graft shortening toward
flexion. If this was not the case the K-wire was repositioned. The
K-wire was overdrilled with a 6 mm cannulated drill bit. A second
hole was drilled in the distal femoral metaphysis to create a bone
tunnel. The graft was introduced into the tunnel and tensioned with
the knee in 20° of flexion. Fixation was achieved with two staples
in a belt buckle fashion or with a screw and soft tissue washer in
the femoral metaphysis.
In two cases we performed a medial collateral ligament recon-
struction using a ST tendon graft. The ST tendon was harvested
leaving it attached distally. A bone tunnel was produced into the
medial femoral condyle, starting at the epicondyle. The position of
the hole at the epicondyle was checked with a K-wire, as described
for the LCL. We aimed at a ligament which was isometric within
2
mm in the arc of motion between 0° and 120°.
Postoperatively the knee was placed in a hinged brace in ex-
tension. Flexion was started on the second postoperative day using
a continuous passive motion machine. Passive flexion exercises
were gradually introduced hanging the leg over the edge of the
bed. Alternatively a physical therapist flexed the knee pulling for-
ward on the calf. Active flexion with contraction of the hamstrings
was avoided. Quadriceps contraction and strengthening was en-
couraged in the range from 0° to 70° of flexion. It was our goal to
achieve 90° of flexion at the end of the first postoperative month,
1
20° by the end of the second, and full flexion within 3 months.
Weight bearing was started as soon as tolerated, and it was pro-
gressed from partial to full during the second postoperative month.
If a lateral reconstruction had been performed, we avoided the
last 20° of extension in the first postoperative month. We encour-
aged the patients to slowly regain full extension during the second
postoperative month. In these cases weight bearing was allowed
6
weeks postoperatively.
Fig.4 Lateral collateral ligament reconstruction using a free semi-
tendinosus tendon graft (see text for explanation)
Results
The graft was pulled distally and fixed in the central part of the
fovea. Graft angulation against the lateral margin of the medial
femoral condyle was carefully avoided. The posterior inter-
The patients were reviewed at an average follow-up of
3.5 years (range 2–5.5). There were no perioperative
condylar area was fish-scaled with a sharp osteotome. With the complications in this series. Two patients developed a
knee in 40–50° of flexion the graft was tensioned and fixed to the
hematoma postoperatively which resolved with conserva-
back of the tibia with two teethed staples (Richards, Memphis,
tive treatment. One knee was manipulated under anesthesia
Tenn., USA) or with a staple proximally and a screw and soft tis-
1
month after the operation because of flexion loss.
Subjectively all the patients described their knee as sat-
sue washer distally. While inserting the staples, care was taken to
angle the device distally to avoid penetration of the joint. The cap-
sular incision was closed, the tourniquet was released, and hemo-
stasis was achieved. The wound was closed as routinely over a
suction drain.
isfactory (normal or nearly normal; Table 1). Symptoms
evaluation was satisfactory in 17 patients for pain and giv-
ing-way, and in all of them for swelling. One patient com-
If increased lateral joint line opening was present, we performed
a lateral collateral ligament (LCL) reconstruction. It was performed plained of patellofemoral pain and giving-way. At follow-

270
Table 1 Results at follow-up
according to the IKDC evalua-
tion form
Normal
8
Nearly
normal
Abnormal Severely
abnormal
Subjective evaluation
10
–
–
Symptoms
Pain
Swelling
Giving-way
11
12
14
6
6
3
1
–
1
–
–
–
Range of motion
Extension loss
Flexion loss
16
9
2
8
–
1
–
–
Ligament examination
Posterior drawer
Reverse pivot shift
Lachman test
Pivot shift
3
16
11
16
15
15
11
2
7
2
3
4
–
–
–
–
–
–
–
–
–
–
–
Medial joint line operation (valgus rotation)
Lateral joint line operation (varus rotation)
3
Patellofemoral crepitation
Harvest site pathology
Final result
9
18
3
8
–
9
1
–
6
–
–
0
up 5 patients participated regularly in level II activities, with pain or tenderness along the upper margin of the
2 in level III, and one in level IV activities. None of the patella suggesting donor site morbidity.
1
patients reported that he was limited to activities of daily
living because of knee problems.
The final result, according to the IKDC form, was sat-
isfactory in 12 knees and unsatisfactory (abnormal) in
There were no knees with an extension loss at follow- 6 knees, because of symptoms (one knee), flexion loss
up evaluation. Knee recurvatum was corrected in all the (one knee) and increased posterior tibial displacement
4
cases in which it was present preoperatively. A flexion (4 knees). A satisfactory final result was achieved by 7 of
loss of 20° was present in one knee. 10 knees with an isolated PCL reconstruction (70%) and
The average posterior tibial displacement using the Te- by 5 of 8 knees with an associated PCL and medial or lat-
los device was 4.6 mm (range 1.6–8) in the lateral com- eral compartment injury and reconstruction (62.5%; n.s.).
partment and 5.1 mm (range 1.6–9.6) in the medial com-
partment. The posterior displacement of the tibial plateau
was 4.8 mm on average. The average displacement was Discussion
0–2 mm in 3 knees, 3–5 mm in 11, 6–7 mm in 2, and
8–10 mm in 2. The tibial step-off, evaluated with the knee The results of this series of PCL reconstructions have
at 90° of flexion, was similar that in to the opposite knee been satisfactory and represent an improvement over our
in 3 cases, decreased in 8, and absent in 7. The reverse previous experience [1]. We routinely employed a quadri-
pivot shift at follow-up was absent in 16 and 1+ in the ceps tendon autograft which was implanted with an open
other 2 knees.
technique and a direct posterior approach and fixation to
The posterior tibial displacement was 4.7 mm in the the tibia. In this group of severe chronic injuries a satis-
0 knees with an isolated PCL reconstruction, 4.5 mm in factory posterior stability (posterior tibial displacement
1
the 6 knees with a lateral compartment reconstruction, and within 5 mm of the opposite normal knee) was restored in
.4 mm in the 2 knees with a medial reconstruction (n.s.). 14 of 18 knees (78%).
In the 6 knees with a lateral reconstruction, lateral joint The choice of the autologous quadriceps tendon has
line opening, evaluated with the Telos device, was within several reasons. Its length, which is 8.6 cm on average,
mm in 5 knees and 3–5 mm in one. An increased exter- was always adequate for this operation and compares fa-
nal tibial rotation at 30° and 90° of flexion persisted in vorably with an average length of 5.2 cm for the patella
knees. In the two knees with a medial reconstruction, tendon [44]. The mean cross-sectional area of a 10 mm
6
2
2
2
stress radiography revealed an increased medial joint line wide quadriceps tendon graft was 64 mm , significantly
opening of 2 mm in the first knee and of 5 mm in the sec- larger than the 37 mm of the patellar tendon. Gross
2
ond.
anatomy observations confirm that the quadriceps tendon
Patellofemoral crepitation at follow-up was moderate is thicker, longer, and wider than the patellar tendon [22].
in 8 knees and symptomatic in one. There were no cases The ultimate failure load of the quadriceps bone-tendon

271
complex was 2173±618 N compared to 1953±325 N of this position. Tensioning of the graft at 45° may be sub-
the bone–patellar tendon–bone complex [44]. Therefore optimal; since high tensile forces are developed in the
the anatomical and structural properties make it a suitable PCL at 90° of flexion [15] graft tensioning should be per-
graft for PCL reconstruction.
formed close to this degree of flexion. Finally, working in
Harvesting of the quadriceps tendon is easily for sur- the prone position is a disadvantage in associated injuries.
geons familiar with harvesting of the patellar tendon. Donor In these knees the best sequence would be to accurately
site morbidity appears to be less than using the patellar reduce the tibia with the knee at 90° of flexion reproduc-
tendon graft. Our patients did not complain of donor site ing a normal step off, followed by tensioning and fixation
pain or increased patellofemoral pain and/or crepitation of the PCL graft and by tensioning and fixation of the pos-
compared to the preoperative status. Favorable results terolateral structures and/or ACL. The alternatives in-
have been reported in the literature when the quadriceps volve working with the patient in the supine [9] or lateral
tendon graft was employed to reconstruct the ACL [16, decubitus position [3]. The posterior approach to the tibia
4
2]. Finally allograft tissues as the patellar or Achilles is somewhat more difficult in both these positions than in
tendon are not readily available in our country. the prone position, especially for the surgeon who is not
Arthroscopic assisted PCL reconstruction has been familiar with it.
recommended and performed with success [12, 13, 21, 28, Accurate positioning of the PCL graft on the femoral
8]. This is an advanced arthroscopic procedure which side is of crucial importance to restore an optimal poste-
3
may be difficult for the surgeon who performs it occa- rior stability. Laboratory studies have shown that the
sionally. Accurate placement of the tibial tunnel is demand- forces in the PCL increase with increasing flexion to
ing. Drilling of the tibial tunnel should be performed with reach maximum tension at 90° [15]. There is a general
caution to avoid injury to the popliteal vessels [25]. The agreement today that reconstruction of the main anterolat-
use of a transtibial tunnel unavoidably causes an acute eral bundle should be the focus of the procedure. To re-
turn in the course of the graft. This increases the difficul- produce the anterolateral bundle the Kirschner wire must
ties of graft passage and may lead to recurrent instability be placed in the anterior part of the femoral foot print, in
if tunnel widening or graft abrasion occur [26]. Finally if a “shallow” position. This “anatomical” femoral position-
a quadriceps tendon graft is used the length of the graft is ing has been shown to give better results than a deeper,
not enough to exit from the tibial tunnel. Distal fixation is so-called “isometric” positioning in terms of objective
achieved with nonabsorbable sutures tied around a post stability in a cadaver model [17]. Variations in graft posi-
screw, which is less than optimal.
tioning on the femoral side have a larger effect on the
To overcome the disadvantages reported above a direct graft tensioning pattern than variations on the tibial side
posterior tibial approach and fixation has been used [3, 9, [20]. Double-tunnel techniques have been proposed [2] to
26]. A direct posterior tibial approach and fixation avoids reproduce more accurately the complex anatomy and
the potential problems of proximal or medial tibial tunnel function of the PCL. Laboratory studies [31, 36, 39] sug-
placement, tunnel widening and graft abrasion. On the gest that a two-bundle PCL reconstruction improves ob-
other hand, the procedure is more traumatic than an arthro- jective stability. The effectiveness of these procedures in
scopic assisted operation. The dissection is limited using the clinical setting remains to be confirmed.
the approach described by Burks and Schaffer [6] which
A final consideration involves the treatment of associ-
avoids sectioning the tendon of the medial gastrocnemius. ated injuries. It has been shown that the posterolateral [18,
Laboratory evaluation of PCL reconstruction using the 19] and the posteromedial [40] structures cooperate with
patellar tendon graft was performed comparing the stan- the PCL to control posterior tibial displacement. A satis-
dard tibial tunnel technique to the direct posterior tibial factory result requires reconstruction of both the PCL and
fixation with lag screw (the so-called “tibial inlay” tech- of the medial or posterolateral structures.
nique) [4]. Twelve pairs of human knees were used. The
Our LCL reconstruction using a free semitendinosus
increase in posterior tibial translation was 4.7 mm on aver- graft was effective in restoring a normal varus tibial rota-
age in the tibial tunnel group and significantly less (1.8 mm) tion in five of six knees. The anatomical insertions of the
in the direct tibial fixation group.
LCL on both the femur and the fibula should be dupli-
Although our technique with a direct posterior tibial cated to achieve a ligament which is tight in extension and
approach and fixation has achieved a satisfactory objec- slackens in flexion. Laxity in flexion is necessary to ac-
tive stability, its use is not without disadvantages. The commodate the greater mobility of the lateral tibial plateau.
main difficulty in our experience is related to positioning In the knees with an increased external tibial rotation over
of the patient. The procedure may be performed in two 10° at 30° and 90° of flexion, a reconstruction of the
steps, as we did, placing the patient supine first and then popliteofibular ligament [33, 47] has been suggested since
prone. In this case the graft is tensioned and fixed in the this structure is better oriented to control external tibial
prone position with the knee flexed 45–60°. Evaluation of rotation. A reconstruction with these characteristics has
the step-off and posterior drawer is virtually impossible in been described by Larson [29] with reported good results.

272
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