OP note
Thank you for your help. Here's the OP note:
I brought his leg into 45 degrees of flexion and made a curvilinear incision. I dissected sharply through the subcutaneous tissue and controlled any bleeding with electrocautery. Once I got to the level of the IT band, I found that there was a tear of the posterior IT band, and the peroneal nerve was visible in the middle of the field. It was contused and loose appearing. The short head of the biceps was torn and retracted proximally with a tear of the lateral head of the gastrocnemius. The fibular head was palpated. There was a vertical tear extending from the posteromedial joint line, anterior and proximally to the lateral epicondyle. The lateral edge of the joint was completely visible. I brought the knee into relative varus and was able to inspect the articular cartilage. I did not see any full-thickness defects. The lateral meniscus was intact, and I was able to palpate and identify the popliteus in the wound. I then irrigated the wound with copious amounts of sterile saline, evacuating the hematoma. I then placed a Penrose drain around the peroneal nerve, freed it around the fibular neck, and released the lateral compartment from its origin. This exposed the nerve at the fibular neck, which was without defect and had a normal appearance. At the level of the posterior fibula, the nerve contusion began. I then performed a neurolysis proximally and carried this deep into the posterior compartment of the thigh. The nerve was intact throughout but was contused in all segments that was visualized. Once this was complete, I retracted this out of the way and protected it throughout the case. I bluntly dissected the conjoined tendon of the biceps tendon free, and this was freely mobile to the fibular head. I then dissected the soleus off the posterior tibia for later passage of the graft. I sharply freed the soft tissue off the anterior fibula for later passage of the graft. I then was able to identify the remnant of the LCL and placed a tagging suture in it. This was torn in its mid substance at the distal third. The remnant on the fibular head was of minimal quality, and I was unable to approximate the native ligament. I then identified the popliteus and tagged it. With the knee reduced in slight internal rotation, I was able to bring the popliteus into its footprint. I cleared it of its soft tissue. I whip stitched the tendon with a #2 FiberWire and drilled and placed a 3.5 mm BioComposite SwiveLock, reducing the popliteus into its origin. I then thawed 2 posterior tibialis allografts on the back table and whip stitched the free ends. They both measured 8 mm once they were prepared. At this point, I planned to augment the popliteus and reconstruct the LCL, popliteal fibular ligaments. I localized for the popliteus limb first, placed a guide pin across the knee to the medial side, aiming slightly anterior and proximally. Once this was in place, I reamed an 8 mm tunnel to a depth of 25 mm and passed the passing sutures for the graft, docked the graft, and secured it with a 9 x 23 mm BioComposite interference screw. I then laid this across the capsular tear to the posteromedial tibia. I placed the tibial guide at the flat area of the posteromedial tibia and made a small, 1-inch incision just medial and distal to Gerdy's tubercle. I dissected sharply to the bone and placed the guide, drilled the drill pin bicortically, taking care to protect the posterior structures. I then reamed a 10 mm tunnel transosseously, passed a passing suture, and passed the popliteal graft into the anterior portion of the knee. At this point, I turned my attention to the LCL, used the native LCL to identify the origin of the LCL on the lateral epicondyle. I confirmed the position by measuring 14 mm from my popliteal insertion. I then placed a second guide pin again across the condyles parallel to the previous and reamed a tunnel to 25 mm, 8 mm diameter. I passed passing sutures for the second graft, docked the tendon, placed a 9 x 23 mm BioComposite interference screw. I then placed a guide pin from the anterolateral cortex of the fibula at the widest portion aiming towards the proximal tib-fib joint. I then reamed a 7 mm tunnel transosseously, used a Hewson suture passer to pass a loop suture, which passed the graft to create my LCL limb. I then retrieved the previously passed popliteus limb and passed both the LCL graft and popliteus through the tibial tunnel, recreating my popliteus and popliteofibular ligament. At this point, I closed the capsule over the popliteus to the posteromedial cortex with #1 Vicryl suture. I irrigated the joint prior to this with copious amounts of sterile saline. Once this was complete, I brought the knee into 30 degrees of flexion and laid it over a bump, kept the foot in neutral rotation and placed a valgus stress, tensioned my LCL limb, and placed a 7 x 23 mm BioComposite interference screw. This gave me excellent varus stability, and I was able to bring the knee into full extension and flex past 90 degrees without difficulty. I then brought the knee back to 45 degrees and tensioned both the popliteus and the popliteofibular ligament reconstructions in neutral rotation with slight valgus stress. I placed a guide pin and an 11 x 35 mm BioComposite interference screw, again capturing the graft. I was able to range the knee past 90 without any difficulty, and the knee was able to reach full extension. There was no recurvatum, and he had excellent stability to varus stress at both 0 and 30 degrees. His external rotation at 30 degrees was symmetric to the contralateral side. I completed the capsular closure posteromedially and then repaired the lateral compartment. I then identified again the biceps tendon, whip stitched it with a #2 FiberWire. I drilled and placed a 4.75 mm BioComposite SwiveLock, reducing the tendon onto the posterior fibula. I then used a tagging suture to create a linked construct to the anterior fibula, laying the tendon across the fibular head. Once this was complete, I tucked the peroneal nerve into the
posterior wound, irrigated the wound with copious amounts of sterile saline, and closed the skin and subcutaneous tissue in a layered fashion.