Medial Collateral Ligament Reconstruction Research Articles

Bone-Demineralized bone-Bone Grafts for Ligament Reconstruction

Ligament reconstruction with the use of novel demineralized bone grafts was investigated in a rabbit model. By demineralizing only the central portions of the long bone samples, the grafts had a configuration of the bone-tendon-bone graft and were flexible in bending. Strip type grafts made from femur, stick type grafts from tibia, and tube type grafts from metacarpal bones were prepared and their performances were evaluated by tensile testing and animal experiments for medial collateral ligament (MCL) and anterior cruciate ligament (ACL) reconstruction. The maximum strength of the strip and stick type grafts were about half of that of MCL, and that of tube type grafts was also about half of that of ACL. The survival rate of strip type grafts in MCL reconstruction was about 50%, and that of stick type was about 60%. In ACL reconstruction, the survival rate of strip type grafts was 0%, that of stick type was 10%, whereas that of tube type grafts was 50%, and that of tube type grafts reinforced with suture was 60%. The strip and stick type grafts might be useful for MCL reconstruction and the tube type grafts might be available for ACL reconstruction with suitable reinforcements.

Reconstruction of the Medial Collateral Ligament for the Medial Instability after Primary Total Knee Arthroplasty - A Case Report -

An absence or compromise of the medial collateral ligament that occurs after primary total knee arthroplasty is a challenging reconstructive problem. Treatment usually requires unlinked-con- strained total knee arthroplasty. R evision with unlinked-constrained prostheses often causes more bone loss and transmits increased stress to the bone-cement and prosthesis-cement interfaces, which can increase the risk of aseptic loosening. However, there are no treatment options other than constrained prostheses. W e present a 47-year-old female who suffered from medial instability that occurred after total knee arthroplasty, which was treated successfully by a medial collateral ligament reconstruction.

Medial Ulnar Collateral Ligament Reconstruction of the Elbow in Throwing Athletes

Background Medial ulnar collateral ligament insufficiency of the elbow can be a devastating injury in the throwing athlete. Reconstruction of the medial ulnar collateral ligament was initially described by Jobe and associates; good clinical results have been described after this procedure. The authors' experience with this technique raised several concerns, and thus the “docking” procedure was developed as an alternative method for medial ulnar collateral ligament reconstruction of the elbow. The early results of the docking technique were good. The authors wish to investigate the intermediate-term clinical results of this method in a large group of athletes. Hypothesis The docking technique can return overhead-throwing athletes to sport with minimal perioperative morbidity. Study Design Case series; Level of evidence, 4. Methods During a 3-year period, 100 consecutive overhead-throwing athletes were treated with surgical reconstruction using the docking technique. The inclusion criteria were as follows: (1) a history of medial elbow pain that prevented throwing, (2) a preoperative standard noncontrast magnetic resonance image demonstrating medial ulnar collateral ligament injury, (3) clinically apparent medial ulnar collateral ligament insufficiency, and (4) an overhead-throwing athlete. At the time of surgery, all patients underwent routine arthroscopic assessment. The ulnar nerve was transposed in 22 cases. The mean follow-up was 36 months (range, 24-60 months). Results Ninety of 100 (90%) patients were able to compete at the same or a higher level than before medial ulnar collateral ligament injury for more than 12 months as noted at the follow-up interval; 7 patients were able to compete at a lower level. Only 3 patients suffered postoperative complications. Conclusion The docking technique reliably returns athletes to competitive throwing with a low perioperative morbidity.

A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow

The initial strength of the intact medial collateral ligament (MCL) of the elbow and the strength of 4 reconstruction techniques were compared. Twenty cadaveric upper extremities were mounted in a custom jig with the elbow at 90 degrees , and a pneumatic cyclic valgus loading protocol was used. The mean peak load to failure was 142.5+/-39.4 N for the intact ligaments and 53.0+/-9.5 N for the docking reconstructions, 52.5+/-10.4 N for the EndoButton reconstructions, 41.0+/-16.0 N for the interference screw reconstructions, and 33.3+/-7.1 N for the figure-eight reconstructions. The peak load to failure of the MCL reconstructions was inferior compared with the intact ligament (P<.001). No difference in strength was found between the docking and single-strand medial collateral reconstruction with the use of an EndoButton for ulnar fixation (P>.05, beta=.14). Both of these reconstruction methods were stronger than the interference screw or figure-eight technique (P<.004). The optimal fixation method for a single-strand MCL reconstruction may require improved interference screws or a modified EndoButton procedure.

Master Techniques in Orthopaedic Surgery

Douglas W. Jackson, editor. Philadelphia: Lippincott Williams and Wilkins; 2003. 460 pages. $199.00 This second edition text updates the many advances in the treatment of knee disorders that have been introduced since the first edition of this book was published in 1995. Classic, timetested knee operations have been updated and presented in the same userfriendly format that was introduced in the first edition. New chapters cover such topics as meniscal fixation, meniscal transplantation, cruciate graft harvesting, medial collateral ligament reconstruction, openingwedge osteotomy, intraarticular …

Paper #200 Chronic medial collateral ligament insufficient knee without cruciate ligament injury

In spite of a high healing potential of a torn medial collateral ligament (MCL), some cases show valgus instability, which is commonly combined with cruciate pathology. However, reports on chronic medial instability without any cruciate ligament injuries have not been conducted. In this study, we described the clinical features of chronic MCL insufficiency without any other ligamentous pathology, and outcomes of MCL reconstruction.

The reconstruction of medial collateral ligament during total knee arthroplasty for severe valgus deformity

The reconstruction of medial collateral ligament during total knee arthroplasty for severe valgus deformity

Two-Stage Reconstruction With Autografts for Knee Dislocations

Traumatic knee dislocations are severe injuries that involve damage to the anterior cruciate ligament, the posterior cruciate ligament, and the lateral or medial ligamentous structures. There are no established methods of treatment. The objective of the current study was to report the clinical outcome of a two-stage autologous reconstruction on nine knees (eight patients). The mean followup was 40.1 months. The first stage of the reconstruction was done at a mean of 2 weeks after the injury, and the posterior cruciate ligament was reconstructed by an arthroscopically assisted technique using contralateral autogenous hamstring tendon as the graft material. Three months later, the second stage of the reconstruction was done for the ligaments that had not healed with conservative treatment. Arthroscopically assisted anterior cruciate ligament reconstruction was done on all of the knees using the ipsilateral autogenous hamstring tendon or bone-patellar tendon-bone as the graft material. At the same time, a medial collateral ligament reconstruction using an autogenous semitendinosus tendon was done on one knee, and reconstruction of the posterolateral ligamentous structures using a biceps tendon was done on three knees. Each of the knees that was reconstructed was capable of full extension, and the mean degree of passive flexion was 139.5 degrees +/- 5.2 degrees. The mean side-to-side difference in anteroposterior total laxity (KT-1000 arthrometer, manual maximum) was 2.3 +/- 1.9 mm. None of the knees had lateral or medial instability. All of the injured ligaments were able to be reconstructed with autografts, and severe contracture was able to be prevented. A good clinical outcome can be achieved when two-stage reconstruction is used for traumatic knee dislocations.

Medial collateral ligament reconstruction with allograft using a double-bundle technique

Medial collateral ligament (MCL) reconstruction has been a topic of controversy in regard to the need for surgical reconstruction as well as the type of surgical reconstruction to be performed. Combined anterior cruciate ligament (ACL) and MCL reconstruction has been found to be associated with a higher incidence of postoperative arthrofibrosis than isolated ACL reconstruction; performing these reconstructions in a staged format has been proposed to avoid this devastating complication. We present a technique for MCL reconstruction that physiometrically re-establishes both anterior and posterior stabilizing components of the MCL and is performed with a limited soft-tissue dissection. This technique can easily be combined with an ACL allograft or hamstring reconstruction without need for staged or significantly delayed procedure. The technical details of this technique allow for stable fixation of an allograft reconstruction to allow for immediate postoperative knee range of motion with low patient morbidity because of the limited surgical approach.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 4 (April), 2002: E19

Early healing processes of free tendon grafts within bone tunnels is bone-specific: a morphological study in a rabbit model

In order to function as effective ligament replacements, free tendon grafts must become firmly healed into bone tunnels as soon as possible. We hypothesized that graft incorporation would be bone-specific. Free semitendinosus tendon grafts were inserted into drill holes in a lapine medial collateral ligament reconstruction model; thus, creating tibial and femoral bone-specific incorporation sites. Femur-semitendinosus tendon-tibia complexes were harvested from 26 rabbits for histological analysis at various healing times: 0, 6, 12, or 24 weeks post-surgery. Incorporation and remodeling of the graft in the chondral callus was much more extensive at the cancellous-filled femoral insertion than within the marrow-dominated tibial insertion, suggesting that tendon graft healing may depend on the cancellous bone architecture at the graft site.

Single-strand ligament reconstruction of the medial collateral ligament restores valgus elbow stability

The purpose of this study was to determine the contribution of the central portion of the anterior bundle of the medial collateral ligament (MCL) to elbow stability and to evaluate the effectiveness of a single-strand MCL reconstruction in restoring elbow stability. Testing of 11 fresh-frozen upper extremities was first performed on the intact elbow and then with the capsule, flexor-pronator muscle group, posterior bundle, anterior or posterior band, and central band cut sequentially. Next, a single-strand reconstruction of the MCL was performed. The elbow was moved passively through a full arc of flexion in both varus and valgus gravity-loaded positions. Ulnar movement with respect to the humerus was analyzed by means of an electromagnetic tracking system. Maximum varus-valgus laxity throughout the arc of supinated flexion and pronated flexion was 6.6° ± 2.4° and 7.4° ± 2.0°, respectively, for the intact specimen, 34.2° ± 5.6° and 37.7° ± 11.8° for the specimen with all of the medial valgus elbow stabilizers cut, and 9.0° ± 2.5° and 10.5° ± 2.7° for the reconstructed specimen. Maximum varus-valgus laxity was not significantly different among any of the sectioning sequences until the central band was cut (P <.0001). There was no significant difference in maximum varus-valgus laxity between the intact and reconstructed elbows (P <.05). Our results demonstrate that the central band is an important valgus stabilizer of the elbow and that a simplified single-strand reconstruction is able to restore stability to the MCL-deficient elbow. (J Shoulder Elbow Surg 2002;11:65-71.)

Medial Collateral Ligament Reconstruction

Medial Collateral Ligament Reconstruction

Reconstruction of Medial Collateral Ligament in Old Posterior Dislocation of the Elbow

Reconstruction of Medial Collateral Ligament in Old Posterior Dislocation of the Elbow

Fracture and Dislocation of the Elbow Treated with Compass Elbow Hinge

Post-traumatic elbow stiffness is a common and disastrous complication after acute elbow injury. Prolonged immobilization universally leads to stiffness. Stable fixation and controlled, gradual increase in range of motion is preferred for the treatment of comminuted intraarticular fracture and acute unstable dislocation of elbow. In comminuted intraarticular fracture of elbow, the Compass Elbow Hinge provides additional stability for fixation devices used to fix intraarticular fractures and simultaneously permits measured and controlled joint mobilization. In instability after reduction of elbow dislocation, the Compass Elbow Hinge helps to protect the soft tissue from undesirable stresses during healing. The purpose of this study is to evaluate the results of the Compass Elbow Hinge in maintaining and restoring mobility in the acutely injured elbow. The authors reviewed 11 consecutive patients who had the Compass Elbow Hinge applied for acute elbow instability. The average duration of application was 7 weeks. Follow-up averaged 18 months, and motion averaged 96 degrees in flexion/extension plane. Concentric stability was restored in all but one case, one case of resubluxation required reconstruction of medial collateral ligament, following which, the elbow was stable. According to the Mayo

Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management.

We performed a retrospective study of knee joint infections after arthroscopic anterior cruciate ligament reconstruction at our institution. Two thousand five hundred anterior cruciate ligament reconstructions were performed between 1988 and 1993. Seven (0.3%) patients experienced postoperative deep infections of the knee. All anterior cruciate ligament reconstructions were performed using arthroscopically assisted techniques. Six (86%) of these patients had concomitant open procedures performed, including meniscal repair, posterolateral corner reconstruction, and medial collateral ligament reconstruction. Four patients had acute (< 2 weeks), two patients had subacute (2 weeks to 2 months), and one patient had late (> 2 months) infections. All patients had positive cultures from knee joint aspirates with the organisms Staphylococcus aureus, Staphylococcus epidermidis, Peptostreptococcus, or a combination thereof. All patients underwent immediate arthroscopic irrigation and debridement. All infections were intraarticular; six patients also had extraarticular sites of infection. Four patients underwent repeat irrigation and debridement at approximately 1 week. The anterior cruciate ligament graft was removed from four patients. All patients were treated with intravenous antibiotics for 4 to 6 weeks, protected weightbearing, and physical therapy. At a mean followup of 29 months, mean knee extension was 0 degree, and mean knee flexion was 122 degrees (range, 70 degrees to 135 degrees). Six (86%) patients had minimal to no pain in their operative knee, and they were satisfied with their functional results.

A New Device and Method for Controlling the Load in Rabbit Medial Collateral Ligament Reconstructions

In order to study the effect of intra-operative tensioning on the laxity and strength of healing ligament grafts in an animal model, a method of quantifying graft tension was needed. In this study a sensitive ligament tensioning device was developed to measure accurately the prefixation loads in the rabbit medial collateral ligament (MCL) graft. To verify that reproducible changes in ligament tension could be created with the tensioning device, a group of animals had their MCL grafts replaced at one of three different graft loads (tight, anatomic, or loose). The tensioning device consists of two posts which move relative to one another by means of an axial screw. The movable post, which is inserted into the tibial bone island of the MCL graft has a series of strain gauges which can measure the tension applied to the graft. The stationary post attaches to the tibial shaft, permitting the ligament graft to be tensioned relative to this fixed point. After graft tensioning and fixation, the animals were euthanized immediately postoperatively and their ligament load-deformation behavior was measured using an Instron materials testing machine. Specific measures of low load behavior was taken to quantify ligament laxity. Our results demonstrate that the tensioning device was capable of reproducibly altering prefixation graft load intra-operatively as well as MCL laxity immediately postoperatively. A baseline of laxity values was thus developed to follow changes in this laxity measure for future studies of MCL graft healing in this model.

Surgical Technique for the Use of Allografts as Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Collateral Ligament, and Lateral Collateral Ligament Substitutes

The use of allograft tissue represents a compelling way to address ligamentous laxity of the knee. We describe our surgical techniques for their use as anterior cruciate, posterior cruciate, lateral collateral and medial collateral ligament substitutes. Arthroscopically assisted techniques are used in the allograft replacement of the anterior cruciate and posterior cruciate ligaments. Either achilles tendon or patellar tendon allografts are used. In each case, secure fixation is attained both proximally and distally so that early motion and rehabilitation is permitted. Lateral ligamentous reconstruction is performed using a “scissor-tail” achilles tendon allograft; an open approach is used. Bone block fixation is used on the lateral femoral condyle while the graft tails are brought individually through the tibia and fibula and appropriately tensioned. so that they act as separate ligamentous restraints on the lateral and posterolateral aspects of the knee. Medial collateral ligament reconstruction also uses an achilles tendon allograft. An open approach is used in which the remaining autogenous tissue is utilized as the deep portion of the ligament. The allograft is then placed into the appropriate anatomic (isometric) position and secured proximally and distally with posterior oblique ligament reinforcement. In each case, attention to isometry and restoration of constraints of these ligaments is required to afford the patient the best chance to regain functional knee stability and motion.

Knee ligament reconstruction: plain film analysis.

New concepts in knee ligament reconstruction have recently emerged, significantly improving the success of surgical reconstruction of anterior and posterior cruciate ligaments, using high-strength bone-patellar tendon-bone grafts, as well as medial and lateral collateral soft-tissue ligament reconstructions. We reviewed plain radiographs of 50 patients with a total of 72 ligament reconstructions to determine radiographic signs of complications. A major early complication relates to reconstructed ligament positioning. Isometric positioning of the reconstruction is important for all ligaments, but it is most crucial for the femoral portion of the anterior cruciate ligament. Three cases of nonisometric ligament positioning were identified, two anterior cruciate ligaments and one medial collateral ligament. Another early complication is graft fracture, identified in two cases of anterior cruciate ligament reconstruction. Hardware failure did not occur in this series. Late complications include motion of the graft (none in this series) and patellar fracture (one case in this series). Effusions resolved by 4 weeks in 92% of the cases. However, prolonged effusions are usually sterile and should not be mistakenly diagnosed as representing a septic joint if they are an isolated finding. Nonunion of the graft within its osseous tunnel is unusual. Union occurred in 79% of cases by 6 weeks and in 95% of cases by 5 months. Osseous tunnel sclerosis alone is not considered a complication. We conclude that postoperative plain film radiography is important for assessment of graft and hardware position as well as for the detection of early and late surgical complications.

A Method for Replacement of the Anterior Cruciate Ligament of the Knee

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