case_images: PMC11723759_01
case_images: Varus stress X-rays were performed, and a side-to-side difference of 5.6 mm was observed at 20  of knee flexion.
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case_images: F1
case_images: This was confirmed with fluoroscopic varus stress views (Fig. 1).
case_images: The mechanical alignment of the patient's lower limbs showed a left and right varus deformity of 3.5  and 1.5  respectively on full-length standing anteroposterior radiograph, with a joint line convergence angle of 2.6  on the left knee (A). A posterior tibial slope angle of 13  was observed on the left knee lateral radiograph (B).
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case_images: F2
case_images: Joint line convergence angle was 2.6 , suggesting that knee joint laxity was partly the cause of varus deformity (Fig. 2).
case_images: Magnetic resonance of the patient's left knee. Coronal (A) and sagittal (B) T2 cuts. The anterior cruciate ligament was ruptured (yellow arrow) and the fibular collateral ligament was detached from the tibia (red asterisk).
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case_images: F3
case_images: There were no other concurrent ligamentous, meniscal, or chondral lesions (Fig. 3).
case_images: A 6-strand semitendinosus and gracilis (HS) autograft was prepared for anterior cruciate ligament reconstruction (A), while for revision PLC reconstruction each HS from opposite side was prepared individually (B).
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case_images: F4
case_images: ACL reconstruction (Fig. 4a), while for revision PLC reconstruction, each HS tendon was prepared with non-absorbable whipstitch sutures (Fig .4b). A diagnostic knee arthroscopy was carried out with no other concurrent chondral or meniscal lesions identified.
case_images: Surgical approach to the PLC on the left knee. A lateral longitudinal skin incision was performed, passing over lateral epicondyle's proximal and Gerdy's tubercle distally (A), followed by neurolysis of common peroneal nerve (B). A suture was whipstitched on each stump of fibular collateral ligament and biceps tendon [C].
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case_images: F5
case_images: Then, a curvilinear lateral skin incision was performed, passing over the lateral epicondyle and Gerdy s tubercle (Fig. 5a), keeping a skin bridge more than 6 cm from the prior incision. The common peroneal nerve (CPN) was identified, dissected free (Fig. 5b) and protected throughout. The FCL and biceps tendon were found to each have avulsed from the tibia, and a non-absorbable suture was applied to each stump. (Fig. 5c).
case_images: PLC reconstruction in left knee: a lateral view of the fibular collateral ligament and popliteus tendon femoral insertion sites preparation as described by Pache et al. (A). A guide pin was drilled posteriorly from the tibial flat spot toward the popliteus musculotendinous junction to prepare the PLT tibial insertion site (B).
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case_images: F6
case_images: On the femur, FCL and popliteus tendon (PLT) graft tunnels were drilled as described by Pache et al. (Fig. 6a). Similarly, for the PLT tibial insertion site preparation, the guide pin was drilled from the tibial "flat spot", distally and medial to Gerdy's tubercle, toward the popliteus musculotendinous junction posteriorly (Fig. 6b).
case_images: Posterolateral corner reconstruction on the left knee. A lateral view of superior tibiofibular joint (A) which served as the fibular collateral ligament distal placement. The guide pin was lateral to medially drilled at the point of maximum fibular collateral ligament tension in full extension, with slack in flexion. This was assessed with a suture around both fibular collateral ligament guide pins, while the knee was taken through a full range of flexion/extension while maintaining "neutral" axial rotation (B).
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case_images: F7
case_images: In the absence of the fibula head, the distal FCL tunnel was placed at the tibial side of the STFJ (Fig. 7a). FCL tension in full extension, with slack in flexion (determined by placing a suture across femoral and tibial guide pins and moving the knee through range of motion whilst maintaining neutral axial rotation), a guide pin was placed and drilled from lateral to medial, parallel to the joint line in the coronal plane, 8 mm posterior to the anterior limit, and 25 mm distal to the superior limit of the STFJ, respectively (Fig. 7b). FCL and popliteus tendon (PLT) grafts were fixed on the femur with interference screws.
case_images: Posterolateral corner reconstruction on the left knee: a lateral view of the HS graft insertion. The popliteus tendon graft was passed through the popliteal hiatus, exiting at the popliteal sulcus deeply to the fibular collateral ligament graft to reproduce the normal anatomic relation (A). The PLT fixation to the superior tibiofibular joint was performed at 60  of knee flexion and neutral rotation (B). The biceps tendon was reattached to the STFJ just posterior to the fibular collateral ligament placement, with the knee held in full extension [C].
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case_images: F8
case_images: The PLT graft was passed in a posteroinferior direction through the popliteal hiatus (Fig. 8a) and thence anteriorly through its tibial tunnel and fixed at 60 knee flexion and neutral rotation (Fig. 8b). Finally, both native stumps were reattached to the STFJ with anchors: the native FCL just proximal to the FCL placement at 30  of knee flexion; and the biceps tendon just posterior to the FCL placement, with the knee in full extension (Fig. 8c).
case_images: At 24 months follow-up. Left knee hyperextension of 5  (A). Near full flexion compared to the contralateral side (B). Double leg squads are observed [C].
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case_images: F9
case_images: At 24-month follow-up, the operated knee ROM was -5 -130 , with the contralateral knee having -5-135  (Fig. 9).