Medial Collateral Ligament Reconstruction Research Articles

A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques

Background: There is little evidence of the biomechanical performance of medial collateral ligament (MCL) reconstructions for restoring stability to the MCL-deficient knee regarding valgus, external rotation (ER), and anteromedial rotatory instability (AMRI). Hypothesis: A short isometric reconstruction will better restore stability than a longer superficial MCL (sMCL) reconstruction, and an additional deep MCL (dMCL) graft will better control ER and AMRI than single-strand reconstructions. Study Design: Controlled laboratory study. Methods: Nine cadaveric human knees were tested in a kinematics rig that allowed tibial loading while the knee was flexed-extended 0° to 100°. Optical markers were placed on the femur and tibia and displacements were measured using a stereo camera system. The knee was tested intact, and then after MCL (sMCL + dMCL) transection, and loaded in anterior tibial translation (ATT), ER, varus-valgus, and combined ATT + ER (AMRI loading). Five different isometric MCL reconstructions were tested: isolated long sMCL, a short construct, each with and without dMCL addition, and isolated dMCL reconstruction, using an 8 mm–wide synthetic graft. Results: MCL deficiency caused an increase in ER of 4° at 0° of flexion (P = .271) up to 14° at 100° of flexion (P = .002), and valgus laxity increased by 5° to 8° between 0° and 100° of flexion (P < .024 at 0°-90°). ATT did not increase significantly in isolated MCL deficiency (P > .999). All 5 reconstructions restored native stability across the arc of flexion apart from the isolated long sMCL, which demonstrated residual ER instability (P≤ .047 vs other reconstructions). Conclusion: All tested techniques apart from the isolated long sMCL graft are satisfactory in the context of restoring the valgus, ER, and AMRI stability to the MCL-deficient knee in a cadaveric model. Clinical Relevance: Contemporary MCL reconstruction techniques fail to control ER and therefore AMRI as they use a long sMCL graft and do not address the dMCL. This study compares 5 MCL reconstruction techniques. Both long and short isometric constructs other than the long sMCL achieved native stability in valgus and ER/AMRI. Double-strand reconstructions (sMCL + dMCL) tended to provide more stability. This study shows which reconstructions demonstrate the best biomechanical performance, informs surgical reconstruction techniques for AMRI, and questions the efficacy of current popular techniques.

Medial Collateral Ligament Reconstruction With Autograft Versus Allograft: A Systematic Review.

Medial collateral ligament (MCL) reconstruction (MCLR) is performed after failed nonoperative treatment or high-grade MCL injury with associated valgus instability. To evaluate clinical outcomes after MCLR with autograft versus allograft. Systematic review, Level of evidence, 4. A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors conducted a search of the PubMed, CINAHL, EMBASE, and Cochrane databases to identify studies comparing outcomes of MCLR with autograft versus allograft. Studies were included if they evaluated clinical outcomes after MCLR using autograft and/or allograft. Any study that included concomitant knee ligament injury other than the anterior cruciate ligament injury was excluded. A quality assessment was performed using the modified Coleman Methodology Score. The initial search identified 746 studies, 17 of which met the inclusion criteria and were included in this review. The studies included 307 patients: 151 (49.2%) patients received autografts, and 156 (50.8%) received allografts. The most used autograft was the semitendinosus tendon (136 grafts; 90.1% of specified allografts), and the only allograft used was the Achilles tendon (110 grafts; 100% of specified autografts). The mean follow-up of the studies was 25.6 months. Postoperative pain (Lysholm scores) ranged from 82.9 to 94.8 in patients receiving autografts and 87.5 to 93 in patients receiving allografts. Postoperative range of motion was full in 8 of 15 (53.3%) patients receiving autografts compared with 82 of 93 (88.2%) patients receiving allografts. Five of the 151 (3.3%) patients who had MCLR with autografts had complications such as infection, instability, and prominent screws. Two of the 156 (1.3%) MCLRs with allografts developed complications of prominent screws and nonhealing incisions. MCLR with either autografts or allografts leads to improved patient-reported, radiographic, and clinical outcomes. Patient-reported postoperative pain was similar in patients receiving either graft type. Other outcomes were difficult to compare between graft types because of nonstandardized reporting and a lack of pre- and postoperative measurements. Therefore, there is no evidence of significantly improved outcomes in the use of either autograft or allograft with MCLR.

Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: Abiomechanical study.

To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5°increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 Nand 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 Nand 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. Level III.

Isometry of anteromedial reconstructions mimicking the deep medial collateral ligament depends on the femoral insertion.

This study aimed to investigate the length change patterns of the native deep medial collateral ligament (dMCL) and potential anteromedial reconstructions (AMs) that might be added to a reconstruction of the superficial MCL (sMCL)to better understand the control of anteromedial rotatory instability (AMRI). Insertion points of the dMCL and potential AM reconstructions were marked with pins (tibial) and eyelets (femoral) in 11 cadaveric knee specimens. Length changes between the pins and eyelets were then tested using threads in a validated kinematics rig with muscle loading of the quadriceps and iliotibial tract. Between 0° and 100° knee flexion, length change pattern of the anterior, middle and posterior part of the dMCL and simulated AM reconstructions were analysed using a rotary encoder. Isometry was tested using the total strain range (TSR). The tibiofemoral distance of the anterior dMCL part lengthened with flexion (+12.7% at 100°), whereas the posterior part slackened with flexion (-12.9% at 100°). The middle part behaved almost isometrically (maximum length: +2.8% at 100°). Depending on the femoral position within the sMCL footprint, AM reconstructions resulted in an increase in length as the knee flexed when a more centred position was used, irrespective of the tibial attachment position. Femoral positioning in the posterior aspect of the sMCL footprint exhibited <4% length change and was slightly less tight in flexion (min TSR = 3.6 ± 1.5%), irrespective of the tibial attachment position. The length change behaviour of potential AM reconstructions in a functionally intact knee is mainly influenced by the position of the femoral attachment, with different tibial attachments having a minimal effect on length change. Surgeons performing AM reconstructions to control AMRI would be advised to choose a femoral graft position in the posterior part of the native sMCL attachment to optimise graft length change behaviour. Given the high frequency of MCL injuries, sufficient restoration of AMRI is essential in isolated and combined ligamentous knee injuries. There is no level of evidence as thisstudy was an experimental laboratory study.

Comparison of Time-Zero Primary Stability Between a Biodegradable Magnesium Bone Staple and Metal Bone Staples for Knee Ligament Fixation: A Biomechanical Study in a Porcine Model.

Bone staples have been shown previously to be a viable modality for cortical tendon graft fixation in ligament knee surgery. However, soft tissue reactions have been reported, making implant removal necessary. Magnesium alloys are a promising material for biodegradable orthopaedic implants, with mechanical properties closely resembling those of human bone. To compare the primary stability of a biodegradable bone staple prototype made from magnesium to bone staples made from metal in the cortical fixation of tendon grafts during knee surgery. Controlled laboratory study. Primary stability of peripheral tendon graft fixation was assessed in a porcine model of medial collateral ligament reconstruction. Two commercially available metal bone staples (Richards fixation staple with spikes [Me1] and spiked ligament staple [Me2]) were compared with a magnesium bone staple prototype for soft tissue fixation. Primary stability was assessed using a uniaxial materials testing machine. Cyclic loading at 50 and 100 N was applied for 500 cycles each, followed by load-to-failure testing. After 500 cycles at 50 N, elongation was 1.5 ± 0.5 mm in the Me1 group, 1.9 ± 0.5 mm in the Me2 group, and 1.8 ± 0.4 mm in the magnesium group. After 1000 cycles of loading (500 cycles at 50 N and 500 at 100 N), elongation was 3.6 ± 0.9 mm in the Me1 group, 3.5 ± 0.6 mm in the Me2 group, and 4.1 ± 1.0 mm in the magnesium group. No significant differences regarding elongation were found between the groups. Load to failure was 352 ± 115 N in the Me1 group, 373 ± 77 N in the Me2 group, and 449 ± 92 N in the magnesium group, with no significant difference between the groups. In this study, the magnesium bone staples provided appropriate time-zero biomechanical primary stability in comparison with metal bone staples and may therefore be a feasible alternative for cortical fixation of tendon grafts in knee surgery. The biodegradability of magnesium bone staples would eliminate the need for later implant removal.

Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Background: Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. Purpose: To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. Study Design: Controlled laboratory study. Methods: Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. Results: sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. Conclusion: In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. Clinical Relevance: In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

Arthroscopic Posteromedial Corner Reconstruction: A Novel Technique and Case Series.

This study aimed to introduce a novel arthroscopic treatment for medial and posteromedial instability of the knee and present the primary and follow-up results. All patients who underwent the arthroscopic approach to treat medial and posteromedial corner instability from 2007 to 2017 were included in this report. Overall, 45 patients were included, among which 75.6% were male. The mean age of patients was 32.2 ± 8.4 years. Overall, 44.4% and 15.6% of patients had associated meniscal injuries and chondral lesions, respectively. The mean follow-up duration of patients was 84.2 ± 25.3 months. Overall, 37 patients developed a full range of motion (82.2%), and most patients (95.6%) showed excellent quadriceps strength (grades 4 and 5). All patients had a normal or 1+ posterior drawer test, Pivot shift test, and Lachman test on physical examination. Moreover, 60% had an associated isolated anterior cruciate ligament injury, 17.8% had an isolated posterior collateral ligament injury, and 17.6% had a combination of more than one ligament injury. One patient developed septic arthritis. Two patients experienced pain, and one pain patient developed pain with a bony spur formation in the medial epicondyle. Three patients showed a 2+ medial collateral ligament (MCL) test (moderate instability) at the final follow-up, all of whom had multi-ligament injuries. All patients, except the three patients who had a failed MCL reconstruction, returned to their previous activities. This study described a novel arthroscopic treatment of MCL injury, and the results showed acceptable postoperative and clinical outcomes. As the use of minimally invasive surgery may minimize multiple complications associated with open surgery, it is suggested that further studies be conducted regarding this approach when faced with patients who have MCL injuries requiring surgery.

Management of Iatrogenic Medial Collateral Ligament Injury in Primary Total Knee Arthroplasty: A Systematic Review.

The medial collateral ligament (MCL) injury is one of the possible complications of primary total knee arthroplasty (TKA), which can lead to coronal-plane instability that requires surgical revision. Injured MCL can result in joint instability and polyethylene wear. Different strategies have been proposed for MCL reconstruction based on the location of the injury. However, there is a lack of clarity regarding the optimal method for handling an iatrogenic MCL injury throughout a TKA. A PRISMA flow diagram was used to guide the systematic literature review. An extensive search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar. Newcastle Ottawa scale checklist was used to assess the methodological quality of the articles. A total of 19 qualitative studies, including non-cadaveric patients with MCL injury during TKA, were identified after analyzing the full text of the articles. All included studies were either retrospective, observational cohort or case series. A total of 486 patients were studied to gather information on the methods used to repair the MCL and their results. Most injuries arose in the tibial attachment, which surgeons mostly realized during the final stages of surgery. Used techniques can be categorized into three main groups: Primary repair, Repair with augmentation, and changing prosthesis characteristics. This systematic review demonstrated that the most popular management of iatrogenic MCL injury was using suture anchors, staples, screws and washers, and more constrained prostheses. The proper method should be decided considering the site of the MCL injury.

Medial Collateral Ligament Reconstruction of the Knee: The Modified Marx Technique With Adjustable-Loop Femoral Fixation and Posteromedial Corner Plication

The medial collateral ligament serves as the primary stabilizer to valgus stress on the medial side of the knee and is the most commonly injured ligament in the knee. Medial collateral ligament reconstruction can provide improved stability and clinical outcomes for patients. Advancements in techniques, including the use of an adjustable-length-loop suspensory fixation device through a longitudinal incision, have been introduced in recent years. The purpose of this Technical Note and video is to provide a minimally invasive method for medial collateral ligament reconstruction with adjustable-loop femoral fixation and posteromedial corner plication.

Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon

The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.

Reconstruction of Superficial Medial Collateral Ligament: Modified Danish Technique with Dual Adjustable Loop Suspensory Fixation

Injury to the superficial medial collateral ligament (MCL) is treated conservatively for low-grade injury and with surgery for high-grade injury, especially in association with cruciate ligament injury. Acute injuries are treated with MCL repair, and chronic injury requires reconstruction. Anatomic MCL reconstruction can be done using free allograft or autograft and fixed using screws or suspensory fixation. We describe here an anatomic technique that is a modification of a Danish technique in which we reroute the semitendinosus, keeping its tibial attachment intact. The semitendinosus is rerouted anatomically in the tibial tunnel, and a graft is then passed anatomically in the femoral tunnel. The graft is fixed in both tunnels with adjustable loop suspensory fixation, which gives the unique advantage of controlled tensioning of the graft for MCL reconstruction. In this technique further re-tensioning is possible if the knee is unstable in valgus stress, even after final fixation.

Weave Technique for Reconstruction of Medial Collateral Ligament and Posterior Oblique Ligament: A Functional Percutaneous Approach Using Gracilis Tendon

Background: Injury to the medial collateral ligament (MCL) is common. MCL injuries, with impairment of its superficial portion, associated with the deep portion, lead to valgus instability and extrusion of the medial meniscus, resulting in instability and increased pressure in the medial compartment, with consequent damage to the cartilage. We can synthesize this set of structures as the medial meniscocapsular complex. Treating medial, superficial, and deep capsular meniscal complex together aims to restore the normal anatomy, stability, and function of the medial meniscus. Indications: • Anterior cruciate ligament with MCL grade III or MCL grade II • MCL grade III or grade II with clinical instability Technique Description: An arthroscopic examination was performed to assess the “floating meniscus” sign and to confirm a tear of the MCL. The gracilis tendon is harvested in a usual fashion, leaving its distal insertion pedicle fixed to the tibial bone. An incision over the medial epicondyle is made, and a 6-mm drill is used to create a 2.5-cm bone tunnel. The passage of the medial subfascial graft is made toward the medial epicondyle. At this point, its fixation is performed with an interference screw. After fixing the anterior arm, we will return with the free portion of the graft in the most posterior portion and also percutaneously. This posterior arm is biologically fixed, closing the sartorius fascia over the 2 arms of the reconstruction with periosteal stitches. Results: Reconstruction tests were performed on cadaver models, obtaining a graft tension without compromising the range of motion (ROM) and a good result in their final analysis. We ended up publishing our results in a clinical study, with good functional results in both the Lysholm and Tegner scores, at a follow-up of 2 years. Discussion/Conclusion: We present an arthroscopic-assisted technique for a medial, percutaneous, aesthetic, and extremely functional approach. A technical limitation of our procedure is the absence of a biomechanical test for the gracilis double reconstruction: a strong point is that we performed some reconstruction tests on cadaver models, obtained good visual results and graft tension without compromising the ROM, and performed a positive clinical study with a minimum follow-up of 2 years. In conclusion, a simple and inexpensive technique that uses known anatomic principles of graft placement, without compromising ROM was performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

DEEP MEDIAL COLLATERAL LIGAMENT RECONSTRUCTION OF THE KNEE RESTORES ROTATIONAL STABILITY THROUGHOUT FULL RANGE OF MOTION WHILE CONTEMPORARY MCL RECONSTRUCTION ONLY DOES IN EXTENSION

AbstractIntroductionHistoric MCL reconstruction techniques focused on the superficial MCL to restore valgus stability while overlooking tibial external rotation and the deep MCL. This study assessed the ability of a contemporary medial collateral ligament (MCL) reconstruction and a deep MCL (dMCL) reconstruction to restore rotational and valgus knee stability.MethodsSix pairs fresh-frozen cadaveric knee specimens with intact soft tissue were tested in four states: 1) intact 2) after sMCL and dMCL sectioning, 3) contemporary MCL reconstruction (LaPrade et al), and 4) dMCL reconstruction. In each state, four loading conditions were applied at varying flexion angles: 8Nm valgus torque, 5Nm tibial external rotation torque, 90N anterior drawer, and combined 90N anterior drawer plus 5Nm tibial external rotation torque.ResultsTransection of the sMCL and dMCL resulted in increased laxity with valgus torque, external rotation torque, and combined anterior drawer plus external rotation. dMCL reconstruction restored external rotation stability to intact levels throughout all degrees of flexion but did not restore valgus stability at any flexion angle. Contemporary MCL reconstruction restored valgus and external rotation stability at 0° and 20° and valgus stability at 40°. In the combined anterior drawer plus tibial external rotation trial, the dMCL restored stability at 20° and improved stability between 40° and 90° flexion. Conversely, the contemporary MCL reconstruction did not restore stability at any degree of flexion.ConclusionDeep MCL reconstruction restored rotational stability to the knee throughout range of motion but not valgus stability. The contemporary MCL reconstruction restored stability only near full extension.

Anatomic Flat Double-Bundle Medial Collateral Ligament Reconstruction

Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL.

Poster 297: Deep medial collateral ligament reconstruction of the knee restores rotational stability throughout full range of motion while contemporary MCL reconstruction only does in extension

Objectives: The past decade has taught the importance of identifying and treating the concomitant injuries that frequently occur at the time of ACL rupture. Failure to do so can result in increased stresses on the ACL graft and subsequently increased risk of failure. While the focus has largely been on the menisci and the anterolateral soft tissues, recent studies have highlighted high frequency at which injuries to the medial structures occur in previously presumed isolated ACL tears and the increased risk of poor outcomes when they are not addressed. Injuries to the medial ligament complex result in valgus and anteromedial rotatory instability (AMRI). Historic MCL reconstruction techniques have focused on the superficial MCL in an effort to restore valgus stability while frequently ignoring the importance of the deep MCL in controlling tibial external rotation. The recent recognition of the importance of the medial ligament complex has led to multiple studies revisiting medial sided anatomy and questioning contemporary MCL reconstruction techniques. The objective of this study is to assess and compare the ability of a contemporary medial collateral ligament (MCL) reconstruction and a deep MCL (dMCL) reconstruction to restore rotational and valgus stability to the knee. Methods: Six pairs fresh-frozen cadaveric knee specimens were included and with intact soft tissue, the distal femur and tibia were potted in PVC pipes to facilitate biomechanical testing using a customized multi-axial knee activity simulator. Four states were tested: 1) intact 2) after sectioning of the sMCL and dMCL, 3) contemporary MCL reconstruction as described by LaPrade et al, and 4) dMCL reconstruction. In each state, the knees were tested under four loading conditions at varying flexion angles (0°, 20°, 40°, 60° and 90°): 8 Nm valgus torque, 5 Nm tibial external rotation torque, 90N anterior drawer, and combined 90 N anterior drawer plus 5 Nm tibial external rotation torque. Results: Transection of the sMCL and dMCL resulted in increased laxity with the application of the valgus torque, external rotation torque, and combined anterior drawer plus external rotation at all flexion angles. dMCL reconstruction restored external rotation stability to intact levels (all p&lt;0.05) throughout all degrees of flexion (Figure 1), yet dMCL reconstruction did not restore valgus stability at any flexion angle (Figure 2). Contemporary MCL reconstruction restored valgus and external rotation stability at 0° and 20° and valgus stability at 40° (p&lt;0.01). In response to a combined anterior drawer plus tibial external rotation, the dMCL restored stability back to the intact level at 20° and improved stability between 40° and 90° flexion (Figures 3 and 4). In contrast, the contemporary MCL reconstruction did not restore stability at any degree of flexion (p&gt;0.05). Conclusions: Deep MCL reconstruction restored rotational stability to the knee throughout range of motion but did not restore valgus stability. The contemporary MCL reconstruction restore stability only near full extension.

Augmentation of the medial collateral ligament using suture tape reduces the recurrence after corrective surgery for severe hallux valgus

BackgroundThe severity of hallux valgus (HV) deformity is associated with recurrence after corrective surgery because of the degenerative change of the medial capsule including the medial collateral ligament (MCL) at the metatarsophalangeal joint. This study aimed to assess the effectiveness of the MCL augmentation using a suture tape anchor of the recurrence of HV and to evaluate the histological changes of the medial joint capsule in HV patients. MethodsThirty-four feet with severe hallux valgus were included and divided into 2 groups. Seventeen feet had the MCL reconstruction using suture tape anchor with a combination of the corrective osteotomy as the suture tape group (mean age, 64.0 years), and other seventeen feet had the corrective osteotomy without MCL reconstruction as the control group (mean age, 62.0 years). HV angle (HVA) and intermetatarsal angle (IMA) on the weight-bearing radiograms and the Japanese Society for Surgery of the Foot (JSSF) score in both groups were compared at the final follow-up. The medial capsule was harvested from other 20 feet with HV and the relationship between the severity of HV and the histological findings was analyzed. ResultsHVA, IMA, and JSSF scores in both groups were significantly improved from preoperatively to the final follow-up (P < 0.01). At the final follow-up, HVA in the suture tape group (9.2°) was significantly smaller than that in the control (15.4°) (P < 0.01). There were no significant differences in the IMA and the JSSF score at the final follow-up between both groups. Histological scores in HV with ≥40° HVA was significantly worse than those in <40°. ConclusionThe medial joint capsule in severe HV deformity showed the degenerative change and the MCL reconstruction using suture tape combined with osteotomy provides a strong medial constraint to prevent the recurrence of the deformity in severe hallux valgus. Level of Clinical Evidence3

Poster 205: Performance and Return to Sport Following Medial Ulnar Collateral Ligament Repair with Internal Brace Augmentation in Professional Baseball Players

Objectives: Medial ulnar collateral ligament (UCL) reconstruction (UCLR) has been the gold standard treatment for symptomatic UCL injuries in throwing athletes. Recently, a novel technique of UCL repair with suture augmentation has been described and shown promising biomechanical as well as clinical results in a few small series of nonprofessional athletes. An added advantage of this technique over UCLR is that it affords the potential ability to return to competitive throwing with an accelerated timeline of 6-7 months as opposed to 12-18 months. No prior work has described the outcomes of this technique in professional athletes. This study aimed to evaluate the frequency and rate of return to prior level of sport as well as athletic performance of professional baseball players following UCL repair with Internal Brace augmentation. Methods: This study included all professional Major League Baseball (MLB) and Minor League Baseball (MiLB) players who underwent primary UCL repair with Internal Brace from January 2016 to June 2021. Demographic and performance data were recorded for each player. Performance metrics were then compared from one year preinjury against one year postoperative metrics. The return to play date was recorded. Univariate statistical analysis was performed to compare preinjury to postoperative performance (p&lt; 0.05 considered statistically significant). Results: Fifteen players met inclusion criteria (8 MLB and 7 MiLB). Mean age was 28.2 +/- 4.06 years at time of surgery. There were 10 pitchers and 5 position players. All injuries were to the dominant extremity. No players underwent revision surgery during the study period. 93.3% (14/15) of players returned to sport and eventually prior level of competition. Average time to return to sport was 11.5 +/- 4.27 months and average time to prior level of competition was 12.1 +/- 4.61 months. When comparing competitive performance of players that returned successfully, one year preinjury to one year postoperatively, there was no statistically significant difference observed in performance [Table 1]. Conclusions: This study demonstrates promising early results of UCL repair with Internal Brace augmentation in professional baseball players. 93.3% of players were able to return to sport in under 12 months. All players, pitcher and position, that returned to sport were able to return to their prior level of play. No statistically significant drop in performance was observed in players that were able to return to play. Further clinical evaluation of UCL repair with Internal Brace augmentation and direct comparison of this procedure with UCL reconstruction is warranted. [Table: see text]

Double-Bundle PCL Reconstruction in the Multiple-Ligament Injured Knee

Background: Multi-ligament knee injuries and knee dislocations are potentially devastating injuries that typically result in injury to both cruciate ligaments and variable injury to collateral ligament complexes. Indications: Surgical intervention typically leads to better patient outcomes than nonoperative management. We describe our preferred technique for bicruciate ligament reconstruction with a focus on double-bundle posterior cruciate ligament (PCL) reconstruction. Technique Description: A transtibial approach is used to drill the PCL tibial tunnel. A safety incision on the proximal medial tibia, which may incorporate the distal aspect of a medial-sided incision for medial collateral ligament (MCL) reconstruction, allows palpation of the PCL fovea for anatomic tunnel placement, protection of the posterior neurovascular structures, and egress of arthroscopic fluid during the case. This technique uses an inside-out approach for creation of the 2 femoral sockets to recreate the 2 PCL bundles. The grafts are passed in antegrade fashion, with passage and femoral fixation of the posteromedial (PM) bundle followed by the anterolateral (AL) bundle. After passage of the anterior cruciate ligament (ACL) graft and fixation on the femur in standard fashion, attention is turned to PCL tibia-sided fixation. We use a screw and spiked washer to fix the AL bundle at 90° of flexion with an anterior drawer maneuver. The PM bundle is then fixed with a polyetheretherketone (PEEK) interference screw in near full extension. Fixation of the ACL on the tibia in standard fashion completes the bicruciate ligament reconstruction. Results: In biomechanical cadaveric studies, double-bundle PCL reconstruction has been shown to more closely approximate native knee kinematics, with more restraint to posterior translation at all knee flexion angles and less internal rotation laxity at higher knee flexion angles. In clinical results, both single-bundle and double-bundle reconstructions improve knee stability and patient-reported outcomes. Double-bundle PCL reconstruction may provide improved objective posterior tibial stability and objective International Knee Documentation Committee (IKDC) scores. Discussion: Double-bundle PCL reconstruction can be performed efficiently with good outcomes and potentially less residual posterior translation or internal rotation laxity than single-bundle PCL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries—Which Is Best? A Systematic Review and Meta-analysis

Background: Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries. Purpose: To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach. Results: In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength. Conclusion: Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

Reduction of Collision Risk in Multi-ligament Knee Injury KD-III-M and KD-IV Surgery—Superficial Medial Collateral Ligament Reconstruction with Suture Anchors

Surgical reconstruction of the medial collateral ligament (MCL) can be challenging during multi-ligament knee injury surgery due to the limited working space. There is risk of collision between the guide pin, pulling sutures, reamer, tunnel, implant, and graft of the different ligament reconstructions. In this Technical Note, we detail our senior author’s technique for superficial MCL reconstruction using suture anchors and cruciate ligament reconstruction with all-inside techniques. The technique mitigates the risk of collision by confining the reconstruction process and implants for MCL fixation on the medial femoral condyle and medial proximal tibia.