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Surgical Approaches to the Posteromedial and Posterolateral Aspects of the Knee Michael J. Medvecky, MD, and Frank R. Noyes, MD Abstract With continuing advances in arthroscopic surgical techniques, open incisions around the knee have become less common and thus are less frequently experienced by physicians in orthopaedic surgery training. In addition, the infrequent use of popliteal fossa surgical dissection and its potential for neurovascular complications lend an undesirable challenge to surgical approaches to the posterior aspect of the knee. Recently, however, posterior cr uciate ligament (PCL) tibial inlay reconstruction, which requires a posterior approach, has received in- creased attention and more frequent use. 1,2 Additional indications for a posterior surgical approach to the knee are inside-out meniscal repair, repair with or without augmentation of acute traumatic medial or lateral ligamentous injuries, reconstr uction of chronic medial or lateral ligamentous injuries, open reduction and internal fixation (ORIF) of tibial plateau fractures (eg, coronal fractures of the medial tibial plateau), ORIF of PCL tibial avulsion fractures, Baker’s cyst excision, posterior capsular releases for arthrofibrosis, and tumor/mass excision. The extensile popliteal exposure, using an S-shaped incision with wide medial-to-lateral dissection, is indicat- ed for some situations, primarily tumor resection. Approaches that pro- vide access to the posterior aspect of the knee on a more limited basis are important when reduced exposure is advantageous. 3 These approaches allow for a focused posterior exposure via the posterior corners of the knee. If access to both the medial and lateral aspect of the popliteal fossa is needed, the approaches can be combined. Understanding the complex anatomy of the posterior knee is critical to properly establish a diagnosis, for- mulate a t reatment plan, pr epare surgical strategy, and repair or recon- struct acute or chronic ligamentous injuries. Inconsistent anatomic termi- nology in the basic science and clinical literature has occasionally led to confusion in the identification of some structures. 4 An accurate delin- eation of the relevant knee anatomy is paramount to understanding the surgical approaches. Anatomy of the Popliteal Fossa and Posterior Corners of the Knee In addition to familiarity with the muscular and ligamentous structures involved in the posterior, posteromedial, and posterolateral approaches to the knee, the neur ovascular anatomy also requires careful attention (Fig. 1). Although the origins of ar- Dr. Medvecky is Assistant Professor, Department of Orthopaedics and Rehabilitation, Yale Univer- sity School of Medicine, New Haven, CT. Dr. Noyes is President and Medical Director, Cincin- nati Sportsmedicine Research and Education Foun- dation, Deaconess Hospital, Cincinnati, OH. None of the following authors or the departments with which they are af filiated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Medvecky and Dr. Noyes. Reprint requests: Dr. Medvecky, Yale University School of Medicine, PO Box 208071, New Haven, CT 05620-8071. Copyright 2005 by the American Academy of Orthopaedic Surgeons. Surgical approaches to the posterior aspect of the knee are not commonly needed, and their use has become even rarer with the increasing sophistication of arthroscopic technology. As a result, physicians in orthopaedic surgical training are not often exposed to the practical use of surgical dissection around the posterior corners of the knee. For certain procedures, however, greater clinical utility and decreased surgical morbidity render focused posterior exposure the preferred alternative to the classic popliteal dissection with its wide exposure of the popliteal anatomy. Surgical indications include ligament repair or reconstruction around the posteromedial or posterolateral aspect of the knee, inside-out meniscal repair, posterior cruciate ligament tibial inlay reconstruction, and Baker’s cyst excision. To minimize complications, these focused approaches require adeptness with the complex anatomy of the posterior, posteromedial, and posterolateral aspects. J Am Acad Orthop Surg 2005;13:121-128 Vol 13, No 2, March/April 2005 121 terial branches in the popliteal space are relatively constant, awareness of potential variations can help prevent injury. 5 The popliteal artery originates at the adductor hiatus and passes through the popliteal fossa. Before passing deep to the fibrous arch over the soleus muscle, it divides into the anterior and posterior tibial arteries at the distal aspect of the popliteus muscle (Fig. 2). At the level of the su- pracondylar ridge, superior medial and lateral genicular arteries are given off. Just proximal to the level of the knee joint, four major arteries are dis- tributed—medial and lateral sural arteries, a cutaneous branch that travels with the small saphenous vein to supply superficial tissues, and the middle genicular artery. Finally, the inferior medial and lateral genicular arteries are given off at approximately the joint line level. Three branches deserve particular attention. The inferior medial genicular artery is located at the superior surface of the popliteus muscle and continues around the medial aspect of the proximal tibia, deep to the superficial medial collateral ligament (MCL). The middle genicular artery arises approximately at the level of the joint line and passes anteriorly to pierce the oblique popliteal ligament and posterior joint capsule and to supply the cruciate ligaments. The inferior lateral genicular artery travels anteriorly, overlying the lateral limb of the arcuate ligament and popliteal musculotendinous junction and the lateral meniscus. 4 Vascular branching patterns are relatively constant, but anatomic variations may place vascular structures at risk. In rare situations, the popliteal artery has been found to pass medial to or within the muscle belly of the medial gastrocnemius head. 6,7 This artery also may pass anterior to the popliteusmusclebelly;thus,subperiosteal dissection of the popliteus muscle belly is favored over a muscle- splitting approach. Schmeiser et al 5 demonstrated that the bifur cation of the sciatic nerve into the tibial and common per oneal nerves Figure 1 Knee anatomy. A, Medial view. Inset: Cutaneous innervation. B, Lateral view. (Figure 1,A inset reproduced from Morganti CM, McFarland EG, Cosgarea AJ: Saphenous neuritis: A poorly understood cause of medial knee pain. J Am Acad Orthop Surg 2002;10: 130-137.) Figure 2 Arterial anatomy in the popliteal space. Surgical Approaches to the Posteromedial and Posterolateral Aspects of the Knee 122 Journal of the American Academy of Orthopaedic Surgeons is not as predictable as the vascular branching patterns. The tibial nerve enters the popliteal space lateral to the popliteal artery and then cr osses over the artery at the midpoint to end medial to the artery as it passes into the soleus arch. The common peroneal nerve lies in the lateral aspect of the popliteal space, medial to the biceps femoris tendon. With the posterolateral approach, straying posterior either to the biceps tendon in the superficial dissection or to the lateral gastrocnemius head in the deeper dissection canpotentially injure this nerve. 8 The medial capsuloligamentous complex (Fig. 3) is composed of both static and dynamic stabilizers. The static stabilizers are the superficial MCL (tibial collateral ligament), the middle third capsular ligament (deep MCL), and the posterior oblique ligament (POL). The superficial MCLav- erages 11 cm in length and 1.5 cm in width; it travels from the medial epicondyle to between 5 and 7 cm below the joint line. 9 The POLoriginates at the adductor tubercle and attaches via three arms to the posteromedial tibia and capsule. 10 Dynamic stabilizers of the medial capsuloligamentous complex include the semimembranosus tendon and tendon-sheath complex, the pes anserine tendons, the medial head of the gastrocnemius, and the vastus medialis muscle. The distal semimembranosus tendon divides into five branches or arms 9-13 (Fig. 3). The direct arm inserts onto the posteromedial corner of the tibia just below the joint line. The anterior arm (tibial or reflected arm) travels anteriorly, paralleling the medial tibial plateau, deep to the POL and superficial MCL. The capsular arm becomes con- tiguous with the POL. The inferior arm travels more distal than the anterior arm and inserts proximal to the tibial attachment of the superficial MCL; this arm also has extensions into the aponeurosis of the popliteus muscle. The oblique popliteal ligament is a thin, broad expansion that travels superolaterally to become con- tiguous with the posteromedial capsule and medial limb of the arcuate ligament. 10-13 Like the medial capsuloligamentous complex, the posterolateral anatomic complex (Fig. 4) contains static and dynamic components. 4,14-18 This complex assists in controlling varus, posterior, and external rotation mo- ments; failure t o address injury to this area can result in failure of cruciate ligament r econstruction. 19-22 Static stabilizers include the lateral (fibular) collateral ligament (LCL), iliotibial tract (ITT), and arcuate complex. Dynam- ic components include the popliteal tendon with its associated popliteofibular ligament, lateral head of the gastrocnemius, and the biceps femoris tendons. The main LCL femoral attachment site is a small (approximately 0.5 cm 2 ) bony depression just proximal Figure 3 Medial capsuloligamentous complex. A, Posterior view. B, Posteromedial view. Michael J. Medvecky, MD, and Frank R. Noyes, MD Vol 13, No 2, March/April 2005 123 and posterior to the lateral epicondyle. 23 The LCL then inserts onto the midlateral edge of the fibular head. The ITT separates into two functional components, the iliopatellar band and the ITT,at the distal femoral region. This complex anatomy was divided into five layers by Terry et al 18 and has three main insertions— Gerdy’s tubercle, the patella, and the lateral intermuscular septum. The arcuate complex is the coalescence of several structures that form an arch near the popliteal musculotendinous junction. The lateral limb of the arcuate ligament inserts just anterior to the fabellofibular ligament on the fibular styloid. The medial limb of the arcuate ligament is formed by the oblique popliteal ligament, which travels laterally to attach either to the posterolateral capsule overlying the lateral femoral condyle or to the in- feromedial edge of the fabella. 4 The long head of the biceps femoris muscle has two main tendinous components. Adir ect arm inserts onto the posterolateral aspect of the fibular head, and an anterior arm crosses lateral to the LCL and inserts on the lateral edge of the fibular head. The short head of the biceps femoris has a main direct tendon insertion onto the superior surface of the fibular head, lateral to the fibular styloid and posterior and medial to the LCL insertion. 14 The popliteus muscle originates at the posteromedial aspect of the tibia, and its tendon inserts onto the femur at a point distal and anterior to the LCL insertion. 23 Through the popliteofibular ligament, the popliteal tendon has a direct connection to the fibular head. The popliteofibular ligament originates at the musculotendinous junction of the popliteus and divides into anterior and posterior bundles to form an inverted Y, the arms of which attach to the tip and posteromedial aspect (anterior bundle) and to the anterior downslope of the medial aspect of the fibular styloid process (posterior bundle). 4 Knowledge of the cutaneous nerves around the knee assists in planning incisions and approaches and can help minimize the potential for postoperative neurologically me- diated pain. 24,25 At the anterior and medial side of the knee, four nerves need to be considered—the termina- tion of the medial femoral cutaneous nerve, the medial retinacular nerve (terminal branch of the nerve to the vastus medialis), the infrapatellar branches of the saphenous nerve, and the terminal (sartorial) branch of the saphenous nerve. 25 The infrapatellar branches exit the adductor canal near the level of the joint line, pierce the sartorius muscle, and travel toward the tibial tubercle; they create the major portion of the infrapatellar nerve plexus, which supplies sensation to the infrapatellar region. 26 The terminal branch of the saphenous nerve emerges between the sartorius and gracilis tendons, lying immediately superficial to the gracilis tendon at the posteromedial joint line. 27 Posteromedial Approach When surgical access to the posteromedial aspect of the knee is required and will be performed in conjunc- tion with arthroscopic procedures, draping the leg free and lowering the foot of the table should allow for sufficient exposure. 8,28 This setup should be verified before the initial preparation and draping of the ex- tremity. Palpable landmarks include the medial epicondyle, posterior aspects of both the medial femoral condyle and tibial plateau, and the joint line. The incision length is adapted to the procedure being performed and the focus of the exposure. For example, for an inside-out meniscal repair, a 3-cm vertical or oblique incision made just posterior to the superficial MCL, with the knee at 90° of flexion, is sufficient (Fig. 5, A [option 1]). Placing the incision too far posterior puts the saphenous nerve and vein at risk. Subcutaneous dissection is performed down to the sartorial fascia. This is incised anterior to the sartorius, and the pes tendons are retracted posteriorly (Fig. 5, B). The anatomic interval created by the posteromedial joint capsule anteriorly, the semimembranosus infe- riorly, and the medial head of the gastrocnemius posteriorly is then developed (Fig. 5, C). Fascia located su- periorly to the semimembranosus insertion on the proximal tibia may need to be incised to allow for im- proved visualization of this interval because the semimembranosus may be firmly adherent to the joint capsule. Complete muscle relaxation by the anesthesiologist can assist in this aspect of the exposure. Compared with the posterolateral approach, the medial gastrocnemius head is usually less adherent to the posteromedial capsule, thus allowing the interval to be created by blunt finger dissection. A Henning popliteal retractor (Fig. 6) or sterile metal ta- blespoon then can be placed in the in- Figure 4 Posterolateral anatomic complex. Surgical Approaches to the Posteromedial and Posterolateral Aspects of the Knee 124 Journal of the American Academy of Orthopaedic Surgeons terval, protecting the popliteal neurovascular structures. When exposure of both the medial and posteromedial aspect of the knee is needed, a slightly larger incision (6 to 10 cm) can be used and centered over the superficial MCL. 29 This incision usually allows sufficient access to the posteromedial corner and the POL, especially in the case of acute medial ligamentous injury. For more extensile exposure of the medial and posteromedial aspect of the knee, a curved incision can be made starting at the posteromedial aspect of the thigh and extending over the joint to the anteromedial aspect of the tibia 11,30 (Fig. 5, A [option 2]). Extended Posteromedial Approach Numerous surgical approaches that allow access to the popliteal fossa and PCL tibial attachment have been described. 5,11,30-33 These approaches use an S-shaped popliteal incision, an L-shaped popliteal incision, or a medial incision. An extended posteromedial incision can be used to gain access to the PCL tibial attachment for an arthroscopically assisted PCL tibial inlay reconstruction. 34 The incision is a slight modification of the inverted “hockey stick” posteromedial incision described by Burks and Schaffer, 33 with elimination of the horizontal incision over the flexion crease. A recent ca- daveric study demonstrated safe and excellent exposure of the PCL tibial attachment using a similar incision. 5 For this approach, the patient is positioned supine and the surgical knee is placed in a figure-of-4 posi- tion. To enhance visualization, the table is rotated 20° to 25° away from the surgical side during the posteromedial approach. A longitudinal incision beginning approximately 2 cm proximal to the flexion crease of the knee is carried distally over the medial head of the gastrocnemius and the posterior border of the semimembranosus tendon (Fig. 7, A). Superficial dissection should be done cautiously to avoid injuring the superficial branches of the saphenous nerve, particularly posterior to the sartorius muscle and the infrapatellar branch of the saphenous nerve as it crosses the sartorius superficially. The sartorial fascia is incised along its posterior border in line with the skin incision (Fig. 7, B). The gracilis Figure 5 Posteromedial approach. A, For focused exposure, a 3-cm vertical incision is made at the joint line, just posterior to the superficial medial collateral ligament (option 1). For more extensive exposure, a curved incision can be made starting at the level of the vastus medialis and extending over the medial epicondyle onto the anteromedial aspect of the tibia (option 2). B, The sartorial (crural) fascia is incised anterior to the sartorius. C, The interval between the posteromedial joint capsule, semimembranosus, and medial head of the gastrocnemius is developed. Figure 6 Henning or popliteal retractor. An- terior (left) and posterior (right) sides. Michael J. Medvecky, MD, and Frank R. Noyes, MD Vol 13, No 2, March/April 2005 125 and semitendinosus tendons ar e then visualized. The pes tendons are retracted anteriorly (taking the saphenous nerve with them), and the semimembranosus tendon is visualized (Fig. 7, C). The dissection then uses the interval between the medial border of the gastrocnemius and the posterior border of the common semimembranosus tendon. With lateral retraction of the medial gastrocnemius, the inferi- or arm of the semimembranosus tendon, which extends to the popliteus, is identified and then cut from its attachment to the posterior border of the common semimembranosus tendon. This exposes thesemimembran- osus tendon insertion onto the posteromedial tibia. An S-shaped retractor is then placed extra-articularly between the semimembranosus tendon and the medial femoral condyle, allowing for anterior retraction of the semimembranosus and pes tendons. The medial head of the gastrocnemius is care- fully retracted laterally with a Richardson retractor and gravity as- sistance, allowing for exposure of the popliteus muscle on the posterior tibia. Care must be exercised at this junc- ture in the procedure because undue retraction can avulse branches off the popliteal artery. The inferior medial genicular artery frequently can be spared, with dissection along the superior and medial bor der of the popliteus muscle. If exposure of the posteromedial tibial surface and/or the PCL fossa is necessary, a Cobb eleva- tor is used to subperiosteally elevate the popliteus muscle off the posteri- or tibia. Posterolateral Approach When the posterolateral surgical approach is combined with an arthroscopic procedure, patient positioning and setup similar to that described for the posteromedial approach should ensure adequate access to the posterolateral corner. 8 Palpable landmarks include the lateral epicondyle, LCL, fibular head, and lateral joint line. Again, for focused exposure (eg, inside-out meniscal repair), a 3-cm skin incision is centered just posteri- or to the LCL, with one third of the incision above the joint line and two thirds below the joint line (Fig. 8, A [option 1]). For more extensile exposure, an incision starting at the distal lateral thigh overlying the lateral epicondyle can be carried distally toward Gerdy’s tubercle or to the posterior aspect of the fibular head, de- pending on the exposure needed for the particular procedur e (Fig. 8,A[op- tions 2 and 3]). The fascial intervals between the iliotibial band (ITB) and the biceps femoris tendon distally and the short head of the biceps femoris slightly more proximally are incised (Fig. 8, B). Caution must be exercised at this point because the inferior lateral genicular artery may be encountered. This artery can be injured during the surgical approach or arthroscopically if aggressive meniscal débridement penetrates the joint capsule. Inadver- tent injury can result in postoperative hematoma formation. In contrast to the medial gastroc- Figure 7 Extended posteromedial approach. A, A skin incision is made over the medial head of the gastrocnemius and the posterior aspect of the semimembranosus tendon. B, The interval between the pes tendons and the medial gastrocnemius is opened and the semimembranosus and popliteus are exposed. C, Subperiosteal dissection of the popliteus can expose the posteromedial aspect of the tibia and the posterior cruciate ligament fossa. Surgical Approaches to the Posteromedial and Posterolateral Aspects of the Knee 126 Journal of the American Academy of Orthopaedic Surgeons nemius-posteromedial joint capsule interval, the lateral gastrocnemius head is more adherent to the posterolateral joint capsule (Fig. 8, C). The interval usually can be identified about 1 cm distal to the joint line, and blunt finger dissection can open the tissue plane just proximal to the fibular head, which may be com- pleted using Metzenbaum scissors. Once a Henning popliteal retractor is placed to protect the neurovascular bundle medially, repair of the lateral meniscus can safely be performed using an inside-out technique (Fig. 9). For a more extensile exposure, an incision can be made centered distally between Gerdy’s tubercle and the fibular head, extending proximally toward the posterior aspect of the ITB. Terry and LaPrade 4 describe three fascial incisions to gain exposure. The first fascial incision splits the anteri- or aspect of the ITB, parallel to its fi- bers. The second incision separates the interval between the ITB and the short head of the biceps femoris muscle, parallel to the long axis of the femur. The third incision is made at the posterior aspect of the long head of the biceps and parallel to the peroneal nerve. Use of the anterior ITB and the ITB-biceps intervals is sufficient for exposure in most cases. 35,36 Summary Despite the advances made in arthroscopic knee surgery, the ability to safely gain access to the posteromedial and posterolateral aspects of the knee remains a useful skill for gen- eral orthopaedic surgeons as well as specialists in knee surgery and sports medicine. Focused appr oaches can be made through incisions that are as small as 2 to 3 cm; more extensile approaches can be used for repair of traumatic injuries or for reconstruc- tive procedures. Thorough knowledge of the anatomy allows procedures to be performed more e fficiently and also decreases the potential for significant complications. The OKO video ″Posterolateral Corner Injuries,″ by Robert F. LaPrade, MD, PhD, is available at http://www5. aaos.org/oko/jaaos/main.cfm. Figure 9 Cross section showing popliteal retractor between the lateral gastrocnemius and the posterior capsule. Figure 8 Posterolateral approach. A, A 3-cm vertical skin incision is made at the joint line, just posterior to the lateral collateral ligament (LCL) (option 1). For more extensive exposure, a gently curved lateral incision can be made centered over the lateral joint line and extended distally to expose the fibular head (option 2). If more posterior access is needed, an S-shaped incision can be curved to the posterior aspect of the fibular head (option 3). B, The interval between the short head of the biceps femoris and the iliotibial band (ITB) is opened. C, Pos- terior retraction of the biceps femoris protects the underlying peroneal nerve and exposes the interval between the posterolateral (PL) joint capsule, lateral collateral ligament, biceps tendon, and the lateral gastrocnemius head, which is bluntly opened. Michael J. Medvecky, MD, and Frank R. Noyes, MD Vol 13, No 2, March/April 2005 127 References 1. Berg EE: Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;11:69-76. 2. Bergfeld JA, McAllister DR, Parker RD, Valdevit AD, Kambic HE: A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Am J Sports Med 2001;29:129-136. 3. Hoppenfeld S, deBoer P: The knee, in Hoppenfeld S, deBoer P: Surgical Expo- sures in Orthopaedics: The Anatomic Ap- proach, ed 2. Philadelphia, PA: JB Lip- pincott, 1994, pp 467-476. 4. Terry GC, LaPrade RF: The posterolateral aspect of the knee: Anatomy and surgical approach. Am J Sports Med 1996;24:732-739. 5. 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Burks RT, Schaffer JJ: A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop 1990;254:216-219. 34. Noyes FR, Medvecky MJ, Bhargava M: Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: An analysis of techniques and a safe oper- ative approach to the popliteal fossa. Arthroscopy 2003;19:894-905. 35. Noyes FR, Barber-Westin SD: Treat- ment of complex injuries involving the posterior cruciate and posterolateral ligaments of the knee. Am J Knee Surg 1996;9:200-214. 36. Noyes FR, Barber-Westin SD: Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med 1996;24:415-426. Surgical Approaches to the Posteromedial and Posterolateral Aspects of the Knee 128 Journal of the American Academy of Orthopaedic Surgeons

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