POL Reconstruction: a Necessity or an Accessory

Abstract

The MCL is the knee ligament that is most commonly injured but is quite often neglected in terms of in-depth research and understanding. This is due to the belief in good healing abilities that there is a belief that MCL injuries are almost certain to be cured conservatively. Commonly, recurrent rupture after ACL reconstruction is due to neglect of MCL rupture. This prompted researchers and orthopedic sports surgeons to think about the importance of the MCL, initiate in-depth research on the MCL, and initiate repair of the ligament. Surgical indications include high-grade MCL injuries, valgus instability that persists on conservative therapy, and low-grade MCL injuries with other ligamentous injuries. The MCL consists of the superficial MCL (sMCL), deep MCL (dMCL) and the Posterior Oblique Ligament (POL).It stabilizes the medial of the knee against the valgus and rotation. The sMCL attachment to the femur covers the EM (Epicondyle Medial) and has a long attachment proximal to the tibia distally. The course of the dMCL has a sloping path from its attachment at the posterior distal of EM to the anterior distal of the proximal tibia. The posterior oblique ligament consists of three arms: the superficial, central (tibial), and capsular. The central arm is the largest and thickest part of the POL. The POL attachment to the medial condyle of the femur is somewhat more posterior and proximal than the EM or posterior and distal to the adductor tubercle, extending to the distal aspect of the semimembranosus tendon and is a thickening of the posterior medial capsule, with a distinct attachment to the medial meniscus. It is fused anteriorly with the sMCL but can be identified by the orientation of the fibers. The sMCL biomechanics found tension in the anterior aspect of the ligament when flexed about 90 degrees and externally rotated. In the posterior part of the sMCL, tension during full extension and internal rotation. The anterior part of the dMCL relaxes at 0-30 degrees and tension at an angle of 60 degrees to full flexion, while the posterior part of the dMCL relaxes more when flexed at 0-100 degrees. The POL is the posterior part of the MCL complex, which will be tensioned during Full Extension and internal rotation. The MCL complex is different in its response to changes in length to the extension, flexion, and knee rotation. The MCL is not isometric. The role of POL, which is quite prominent in the medial corner of the posterior knee, holds the movement of internal rotation, so this ligament is not accessory. Rupture of POL requires reconstruction to maintain the internal rotation stability of the knee joint. Furthermore, in performing reconstruction, the POL must be tightened and fixed in full knee extension and neutral rotation to reproduce its anatomical length and prevent over-tightening.