Editorial Commentary: Anatomic Tibiofibular and Partially Anatomic-Based Fibular Posterolateral Corner Reconstruction Techniques Are Biomechanically Superior to Non-Anatomic Reconstruction Techniques: A Tibial Tunnel is the Gold Standard for An Anatomic Reconstruction.

Nearly two decades ago, the posterolateral corner (PLC) was commonly referred to as the "dark side" of the knee due to our limited anatomical understanding, no anatomic-based reconstruction techniques, and high rates of clinical failures. During this time, non-anatomic PLC reconstruction techniques, or "fibular slings", gained popularity early on due to ease of the procedure; however, clinical studies demonstrated residual varus gapping and external rotation laxity associated with these non-anatomic techniques that only reconstructed the fibular (lateral) collateral ligament (FCL). The term "anatomic" PLC reconstruction generally refers to a procedure that aims to restore the entirety of the 3 main PLC static stabilizers. Currently, the most commonly utilized PLC reconstruction techniques have evolved to be either a complete anatomic reconstruction with a tibiofibular-based (LaPrade and Engebretsen) approach or a partial anatomic reconstruction through a fibular-based (Levy/Marx, Arciero) technique. Both reconstruction approaches incorporate the use of a second femoral tunnel for improved restoration of the femoral attachments of the FCL and popliteus tendon (PLT) and are biomechanically superior compared to the historic non-anatomic techniques. As such, these improved PLC reconstruction techniques, whether tibiofibular-based or fibular-based, are strongly recommended over non-anatomic reconstruction techniques. Compared to the fibular-based approach, an anatomic tibiofibular-based PLC reconstruction more closely recreates the native architecture of the PLC with recreation of the PFL and use of a tibial tunnel to restore the static function of the PLT. In addition, certain conditions, such as concurrent proximal tibiofibular joint instability and asymmetric knee hyperextension are contraindications to using fibular-based reconstructions and should always utilize a tibial tunnel.