Medial Collateral Ligament Reconstruction Research Articles

Right knee ACL, PCL and MCL reconstruction with sports-related anxiety

Introduction: JM, a 20-year-old male professional ice hockey player, presented with a 2-week history of lack of range of motion, weakness, and pain in his right knee, after a 2-year post-medical collateral ligament repair of the right knee and 3 year-post anterior cruciate ligament, posterior cruciate ligament and medial collateral ligament reconstruction of the right knee. Case Description: In the course of history taken, it was revealed that 5 months prior to admission the patient had been informed by a psychiatrist that he had sport-related anxiety. With an unremarkable psychiatric history prior to age 18, the competitive nature of his sports career in addition to financial pressure may have contributed to his sports-related anxiety. His examination findings were consistent with a diagnosis of complete tears of the right anterior cruciate ligament and posterior cruciate ligament along with grade III medial collateral ligament injury. Discussion: The biopsychosocial model was used to explicate JM's case. JM's current injuries prompted reconstruction of the anterior cruciate, posterior cruciate, and medial collateral ligaments. Psychologically, JM's sports-related anxiety is not a rare phenomenon as recent studies have discovered an increased risk of sports-related anxiety amongst young professional athletes. Sports-related anxiety, along with competitive trait anxiety, may be factors that contribute to sports injury occurrence. Other psychological stressors can add to sports-related or competitive trait anxiety, further increasing the risk of sports injury reoccurrence. Summary: JM was admitted for a right knee open medial collateral ligament repair with internal bracing, anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction, and platelet rich plasma injection. As part of a holistic patient-centered treatment plan, a referral to psychiatry was made to address JM's sports-related anxiety with the goal of decreasing future risk of sports injury. Patient's Consent Obtained: Yes

Adjustable Loop Fixation in Multi-ligament Knee Injuries: A Technical Note.

Adjustable Loop Fixation devices (ALD) were introduced to allow tensioning and re-tensioning while increasing flexibility of graft length in the bone tunnel. ALDs have shown comparable clinical and biomechanical results when used for anterior cruciate ligament reconstructions. We routinely use ALDs in multi-ligament knee reconstructions. In double bundle posterior cruciate ligament reconstruction, using an ALD, we can achieve differential tensioning of the anterolateral and posteromedial bundles utilizing two femoral and one tibial tunnel. When performing an anatomic posterolateral corner reconstruction using our modification of the anatomical LaPrade technique, an ALD permits differential tensioning of the fibular collateral ligament and popliteus tendon/popliteofibular ligaments with a single graft. In anatomic superficial medial collateral ligament reconstructions, ALD allows for tensioning from the femoral side, subsequent cycling, followed by re-tensioning to achieve a stable reconstruction. In conclusion, ALDs provide numerous benefits when performing multi-ligament knee reconstructions. ALDs allow for appropriate tensioning and re-tensioning which is helpful in removing creep from the graft to prevent postoperative laxity. Additionally, it permits differential tensioning which helps achieve accurate tensioning of individual bundles to help restore native knee kinematics.

Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes.

This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play(RTP) rates and levels, career longevityand complications. A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTPwas defined as competing at professional levelor national/international level in amateur sport. There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP. Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications. Level IV.

Does Combined Reconstruction of the Medial Collateral and Anterior Cruciate Ligaments Provide Better Knee Function? A Systematic Review and Meta-Analysis.

Objective: This study aimed to determine if medial collateral ligament reconstruction (MCLR) alongside anterior cruciate ligament reconstruction (ACLR) preserves knee functionality better than isolated ACLR in combined ACL and MCL tears. Methods: MEDLINE, EMBASE, Scopus, CENTRAL, and Web of Science were searched systematically on 31 March 2023. Studies reporting post-operative function after ACLR and ACLR + MCLR in combined injuries were included. Outcomes included International Knee Documentation Committee (IKDC) score, side-to-side difference (SSD), Lysholm, and Tegner scale values. Results: Out of 2362 papers, 8 studies met the criteria. The analysis found no significant difference in outcomes (MD = 3.63, 95% CI: [-5.05, 12.3] for IKDC; MD = -0.64, 95% CI: [-3.24, 1.96] for SSD at 0° extension; MD = -1.79, 95% CI: [-4.61, 1.04] for SSD at 30° extension; MD = -1.48, 95% CI: [-16.35, 13.39] for Lysholm scale; MD = -0.21, 95% CI: [-4.29, 3.87] for Tegner scale) between treatments. Conclusions: This meta-analysis found no significant difference in outcomes between ACLR and ACLR + MCLR, suggesting that adding MCLR does not provide additional benefits. Due to the heterogeneity and quality of the included studies, further high-quality randomized controlled trials are needed to determine the optimal treatment for combined severe MCL-ACL injuries.

Tenodesis Anchors: A Convenient Technique for Collateral Ligament Reconstructions

Collateral injuries are usually found in association with cruciate ligament tears. There are multiple techniques to reconstruct the collateral ligaments using autografts and allografts. Conventionally, interference screws are used to fix the graft on the femur, tibia, and fibula. We describe a technique that does not require extensive graft preparation and is simple, reproducible, and less time-consuming using tenodesis anchors that give both compression and stability at the graft insertion sites. In this article, we describe posterolateral corner and medial collateral ligament reconstructions using this technique.

Paper 21: Anatomic Medial Ulnar Collateral Ligament Reconstruction with Internal Brace Augmentation in Throwing Athletes

Objectives: Injury to the Medial Ulnar Collateral Ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12-18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL which may contribute to the prolonged course of rehabilitation. In recent years, we described an anatomic MUCL reconstruction with internal brace augmentation which demonstrated improved biomechanical strength when compared to the docking technique in cadaveric specimens. The purpose of this study was to evaluate the postoperative course of both amateur and professional throwing athletes that underwent anatomic MUCL reconstruction with internal brace augmentation. We hypothesized that throwers would return to the same level of play and that return to play (RTP) would be a shorter duration compared to current reported outcomes. Methods: In this surgical technique, the native MUCL is formally repaired. The graft and a suture tape are folded over a suspensory loop and secured in a socket of the medial epicondyle of the humerus to maximize tendon to bone contact. On the ulnar side, the graft and internal brace are secured proximally by two suture anchors on either side of the sublime tubercle and further secured across the sublime tubercle ridge distally to re-create the anatomic triangular insertion of the native ligament. All surgeries were performed by a single surgeon. Patient reported outcomes in addition to date of RTP, level of play, and functional outcomes were retrospectively gathered. All patients initially followed an Accelerated Rehabilitation Protocol and were converted to a Standard Paced protocol if setbacks were encountered. Results: A total of 26 baseball players underwent primary (n=23) or revision (n=3) MUCL reconstruction with the Anatomic Technique. Of these, 15 were professional and 11 were amateur athletes. 92% of throwers returned to play at a mean of 9.9 months following reconstruction. 89% were able to advance through the accelerated postoperative protocol without issues and 85% returned to the same role and level of play. Post injury KJOC scores improved from 41 to 86.9 and SANE scores improved from 32.5 to 95.5. No significant difference was identified in pre-injury versus post-reconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. Conclusions: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries. Advantages include increased tendon-bone contact of the reconstruction, multiple fixation points, and anatomic restoration of the MUCL. This technique allowed an expedited return to sport for these baseball athletes.

Double-Bundle Medial Collateral Ligament Reconstruction Improves Anteromedial Rotatory Instability

Background: New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)–injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. Purpose: To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL–deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. Results: Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR (P < .05). All reconstructions restored VR to the intact state except at 90° of knee flexion (P < .05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position (P < .05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT (P < .05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion (P < .05). Conclusion: In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. Clinical Relevance: In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs.

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

Background: Medial collateral ligament (MCL) reconstruction (MCLR) is performed after failed nonoperative treatment or high-grade MCL injury with associated valgus instability. Purpose: To evaluate clinical outcomes after MCLR with autograft versus allograft. Study Design: Systematic review, Level of evidence, 4. Methods: 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. Results: 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. Conclusion: 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.