Medial Collateral Ligament Repair Research Articles

Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle.

When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. Level IV.

Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair

To evaluate the incidence of early postoperative complications and revision surgery in patients who underwent primary medial ulnar collateral ligament (MUCL) repair with minimum of 2-year follow-up. A retrospective review of a national insurance database was conducted to identify patients with MUCL injuries who underwent primary MUCL repair between 2015 to 2020 with minimum 2-year follow-up. Patients >40 years of age and those who had concomitant elbow fractures or dislocations, lateral UCL injures, medial epicondylitis, elbow arthritis, or a history of previous elbow injury/surgery were excluded. The number of patients who underwent a concomitant ulnar nerve procedure (transposition or decompression) during the primary MUCL repair was recorded. Complications within 90 days of surgery and the incidence and timing of subsequent ipsilateral ulnar nerve surgery or revision MUCL surgery were assessed. A total of 313 patients (63.6% male) were included. The mean age was 20.3 ± 6.9 years, and mean follow-up was 3.7 ± 1.3 years. Concomitant ulnar nerve transposition or decompression was performed in 34.2% (N=107). The early postoperative complication rate was 7.3% (N= 23). The most common complication was ulnar neuropathy (5.8%, N= 18). Wound complications, elbow stiffness, and medial epicondyle fractures were much less common (N= 5). Sixteen of 18 (88.9%) patients with postoperative ulnar neuropathy underwent transposition or decompression at the time of primary repair. Of these 18 patients, 5 (27.8%) underwent a subsequent ulnar nerve surgery (1 primary and 4 secondary), with the majority occurring within 6 months. The incidence of revision MUCL surgery was low (1.0%, N=3), with all 3 patients undergoing MUCL reconstruction. There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. All 3 (1.0%) MUCL revisions underwent reconstruction. Level IV, therapeutic case series.

Open Medial Meniscotibial Ligament Repair With Concomitant Open Superficial Medial Collateral Ligament Repair With Internal Brace Augmentation

The medial collateral ligament (MCL) is the most commonly injured ligament in the knee. Historically, nonsurgical management for these injuries has been favored for a majority of grade I-III sprains, particularly femoral-based. However, when coupled with other injuries such as meniscotibial ligament tears or distal Stener type avulsion tears, early surgical management for these cases is recommended. This will allow for stabilization and protection of the meniscus in addition to preventing residual valgus laxity, especially related to more severe Stener-like avulsions of the superficial MCL that can be seen with meniscotibial ligament tears. Utilizing an open approach, meniscotibial repair with suture anchors with internal brace augmentation for the MCL repair can provide a strong final construct, and a safe and fast recovery.

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.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness

To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up. A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR). A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n= 13) or bicruciate (KDIII-M; n= 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n= 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n= 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0). In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up. Level IV, therapeutic case series.

Machine learning can accurately predict risk factors for all-cause reoperation after ACLR: creating a clinical tool to improve patient counseling and outcomes.

Identifying predictive factors for all-cause reoperation after anterior cruciate ligament reconstruction could inform clinical decision making and improve risk mitigation. The primary purposes of this study are to (1) determine the incidence of all-cause reoperation after anterior cruciate ligament reconstruction, (2) identify predictors of reoperation after anterior cruciate ligament reconstruction using machine learning methodology, and (3) compare the predictive capacity of the machine learning methods to that of traditional logistic regression. A longitudinal geographical database was utilized to identify patients with a diagnosis of new anterior cruciate ligament injury. Eight machine learning models were appraised on their ability to predict all-cause reoperation after anterior cruciate ligament reconstruction. Model performance was evaluated via area under the receiver operating characteristics curve. To explore modeling interpretability and radiomic feature influence on the predictions, we utilized a game-theory-based method through SHapley Additive exPlanations. A total of 1400 patients underwent anterior cruciate ligament reconstruction with a mean postoperative follow-up of 9years. Two-hundred and eighteen (16%) patients experienced a reoperation after anterior cruciate ligament reconstruction, of which 6% of these were revision ACL reconstruction. SHapley Additive exPlanations plots identified the following risk factors as predictive for all-cause reoperation: diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. XGBoost was the best-performing model (area under the receiver operating characteristics curve of 0.77) and outperformed logistic regression in this regard. All-cause reoperation after anterior cruciate ligament reconstruction occurred at a rate of 16%. Machine learning models outperformed traditional statistics and identified diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair as predictive risk factors for reoperation. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. These models will allow surgeons to tabulate individualized risk for future reoperation for patients undergoing anterior cruciate ligament reconstruction. III.

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]

Clinical and Patient-Reported Outcomes of Acute Percutaneous Repair of Medial Collateral Ligament in the Multiligamentous Injured Knee

Clinical and Patient-Reported Outcomes of Acute Percutaneous Repair of Medial Collateral Ligament in the Multiligamentous Injured Knee

Repair of the Medial Ulnar Collateral Ligament of the Elbow With Internal Brace Augmentation

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force across the elbow during throwing. The incidence of MUCL continues to rise, and injuries are common in overhead throwing athletes often leading to elbow pain and instability. While MUCL reconstruction remains the gold standard for high-level throwing athletes with midsubstance tears, MUCL repair remains an option for select athletes and affords good functional outcomes with quicker return to sport compared with reconstruction. Indications: Indications for MUCL repair include acute injuries, proximal or distal avulsions, young and lower demand athletes, non-throwing athletes, or older athletes who may be nearing retirement. Technique Description: An incision is made over the medial elbow from the medial epicondyle to the sublime tubercle. Dissection is carried down to fascia which is split in line with its fibers. The flexor pronator muscle group is bluntly divided, and the ligament exposed. Care is taken to identify and dissect the native ligament. The avulsed portion of the ligament is secured with a 0 FiberWire suture in a running locked whipstitch fashion. The footprint of the avulsed ligament is gently debrided and prepared using a scalpel. The 0-FiberWire suture tails are then loaded onto a suture anchor preloaded with suture tape. This is then secured at the footprint of the ligament. The FiberWires are cut, and the suture tape is then pulled back over the native ligament and fixed at the other attachment site for the ligament. 0-Vicryl sutures are then used to suture the internal brace to the underlying ligament so the construct would move as a single unit. Results: Biomechanical testing has demonstrated that MUCL repair with internal brace augmentation has similar time-zero failure strength when compared with the original Jobe reconstruction technique while also having greater resistance to gapping. In addition, recent literature has shown that well-selected patients can have excellent functional outcomes and quicker return to sport with MUCL repair as opposed to reconstruction. Discussion: Medial ulnar collateral ligament repair with internal brace augmentation can be a successful treatment in the appropriately indicated athlete to allow for good functional results and quicker return to sport. 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.

Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies.

Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads. To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction. Systematic review. The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases. After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008). MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.

Material Properties of Suture Augmentation of Knee Medial Collateral Ligament Repair Did Not Influence Length Changes or Failure Loads in a Caged Porcine Model

To investigate whether the biomechanical properties of the healed superficial medial collateral ligament (sMCL) repaired by augmentation vary depending on the material properties of the suture augmentation. In 8 of 10 porcines (16 hindlimbs), the sMCL was detached from the femoral attachment using a scalpel under intubated general anesthesia. sMCL repair was performed using an ultra-high-molecular-weight polyethylene (UHMWPE) tape for the right hindlimbs and polyester tape (PE) for the left hindlimbs. They were sacrificed at 4 weeks postoperatively. The remaining 2 animals were assigned to the native control group (left and right hindlimb; n= 4). All connective tissues and suture augmentation, except for the repaired sMCL, were removed, and their biomechanical properties were evaluated. No significant differences were observed in the upper yield load (PE group, 247.4 ± 116.0 N; UHMWPE group, 279.9 ± 95.7 N; and sham group, 231.6 ± 50.6 N; P= .70), maximum yield load (PE group, 310.1 ± 166.1 N; UHMWPE group, 334.6 ± 95.2 N; and sham group, 290.9 ± 42.3 N; P= .84), linear stiffness (PE group, 43.3 ± 16.5 N/mm; UHMWPE group, 52.0 ± 28.2 N/mm; and sham group, 44.7 ± 7.2 N/mm; P= .66), and elongation at failure (PE group, 9.4 ± 4.3 mm; UHMWPE group, 9.1 ± 2.7 mm; and sham group, 10.1 ± 2.1 mm; P= .89). Statistical analysis of failure modes showed no significant difference between the groups (P= .21). The material properties of suture augmentation used for sMCL repair did not significantly influence length changes during cyclic loading, postoperative structural properties, or failure modes. The results of this study provide valuable information regarding the efficacy of suture augmentation repair regardless of the materials used.

The Rate of Medial Ulnar Collateral Ligament Repair Is Increasing While Reconstruction Remains the Most Common Procedure Overall Among Early-Career Orthopaedic Surgeons

The Rate of Medial Ulnar Collateral Ligament Repair Is Increasing While Reconstruction Remains the Most Common Procedure Overall Among Early-Career Orthopaedic Surgeons

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.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles’ tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles’ tendon, and deltoid ligament repair demonstrate improved time-zero biomechanical and promising short- to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint overconstraint, nerve paresthesia, and infection. Level of EvidenceLevel V, expert opinion.

Change in humeral anchor position significantly affects isometry in ulnar collateral ligament repair: a 3-dimensional computer modeling study.

Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. Although previous literature has illustrated the importance of tunnel position on restoring graft isometry in reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. The purpose of this study is to design a 3-dimensional (3D) elbow model to understand the effect of anchor location on UCL repair isometry. A 3D computer model of an elbow joint was created using computed tomographic and magnetic resonance imaging MRI scans from a single patient. The humeral and ulnar attachments of the UCL were plotted using 3 methodologies: (1) geometric cloud mapping and (2) quantitative measurements from the anatomic studies by Camp etal and (3) Frangiamore etal. A 3.5-mm-diameter clockface was placed on each attachment site, which allowed for simulation of 12 distinct 1.75-mm deviations in anchor position. The 3 models were ranged through 0°-120° at 10° increments, and the 3D distances were measured between the ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and construct lengths were again measured to evaluate changes in isometry. A paired Student t test was performed to determine if there was a significant difference in isometry between the humeral and ulnar anchor deviations. Using method 1, the UCL repair length at 90° of elbow flexion was 26.8 mm. This construct underwent 13.6 mm of total excursion for a 46.4% change in length throughout its arc of motion. Method 2 produced a 19.3-mm construct that underwent 0.8 mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5-mm construct that underwent 2.3 mm of excursion for a 9.4% length change. Identifying ligament footprints using the quantitative anatomic measurements from Camp etal and Frangiamore etal improved construct isometry through 120° of flexion (length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique alone (46.4% length change). Humeral anchor deviations produced a significant increase in repair construct excursion compared with ulnar anchor deviations (P<.001). When performing UCL repair, small deviations in humeral anchor position may significantly influence ligament repair isometry. Using quantitative anatomic data may help identify anchor positions with improved repair isometry. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics.

Traumatic Great Toe MCL Avulsion in Professional Athlete Treated Surgically with MCL Repair with Suture Tape Augmentation Allowing Rapid Return to Sport

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Acute medial collateral ligament (MCL) tears of the great toe metatarsophalangeal joint (MTPJ) are a rare occurrence. There is minimal literature existing regarding both operative and non-operative management of this pathology, also known as 'traumatic bunion' due to its low incidence. The closest analog is a traumatic ulnar collateral ligament (UCL) rupture in the hand (Skier's thumb). Suture anchor repair with an internal brace has proven to be an effective treatment for thumb UCL tears with rapid rehabilitation and early range of motion. This method has not yet been reported in literature for a weightbearing joint such as the hallux MTPJ. We present a case report for a professional surfer with traumatic great toe MCL avulsion with surgical technique allowing rapid return to sport. Methods: We present a case report of a novel technique for this rare traumatic MCL avulsion. Surgical management of the great toe MCL was performed utilizing a pre-loaded interference screw to fixate suture at the MCL origin with suture tape augmentation. A mid-axial medial approach was used with L-shaped capsular flap to expose the MCL. 3-0 braided suture was passed through the proximal avulsed MCL. A drill tunnel was prepared at the MCL origin, and the MCL was repaired to its anatomic origin with an interference screw technique for knotless technique. The interference screw was preloaded with suture tape. The suture tape from the interference screw was passed extra articular and the capsule was repaired. The sutuer tape was then inserted into the MCL insertion on the distal phalanx using a small interference screw and drill tunnel for a suture tape augmentation while the toe was held in neutral MTPJ position. Results: He was made weightbearing as tolerated in a CAM boot post-operatively. Immediate active great toe MTPJ motion was permitted. At 2 weeks post-op, sutures were removed, and he was allowed self-directed passive range of motion of the toe, with continued weightbearing as tolerated in the boot. All restrictions were lifted at 4 weeks for a return to play protocol and the patient resumed surfing immediately at that time. His last follow up appointment was at 3 months post-op, at which time he had resumed full activity, had no deformity recurrence, no pain, and his range of motion was symmetric to the contralateral foot. The patient was able to compete at full activity in a national tournament to continue the professional tour at 3 months post- operatively. Conclusion: This report demonstrates a novel surgical technique for the treatment of a rare traumatic MCL avulsion of the great toe (the 'traumatic bunion'). In this case of great toe MCL repair in a professional surfer, we utilized a knotless technique to repair the MCL to it's anatomic origin and also provide suture tape augmentation to allow rapid rehabilitation. This report demonstrates rapid return to sport, an excellent outcome, easy rehabilitation, and straightforward surgical technique. More research will be needed to demonstrate the success of this technique in a broader population.

Primary Repair of Medial Collateral Ligament Tears With Suture Augmentation

Background: The medial collateral ligament (MCL) is considered to have superior healing and has classically been treated nonoperatively in low-grade MCL injuries. The MCL injury in the setting of concomitant anterior cruciate ligament (ACL) injury is usually treated with a delay of surgery to allow for nonoperative MCL treatment. Recent studies have shown that even with grade II MCL injury there may be residual laxity which may affect place greater strain on an ACL graft in the multi-ligamentous setting and can be corrected for with early primary repair of the MCL which also allows for early definitive treatment of concurrent ipsilateral ligamentous injuries. Indications: All patients are potential candidates given sufficient tissue quality for repair; however, this procedure is preferably performed acutely to avoid scarring, quadriceps strength loss, and allow for early intervention to any concurrent ipsilateral ligamentous knee injury. This technique may be performed on both proximal and distal MCL injuries with the same anchor positioning in either case. Technique Description: The torn superficial and deep MCL are sutured using a Bunnell-type pattern. The superficial proximal MCL is then fixed to its anatomic footprint using a suture anchor preloaded with an internal suture tape augmentation. A second small incision is made over the tibial insertion of the MCL and a passing suture is channeled from the distal to proximal incision under a skin bridge to retrieve the suture tape. The suture tape is then deployed with appropriate tensioning to the anatomic distal insertion point of the superficial MCL using a second suture anchor. Results: There is currently no published data regarding patient outcomes after MCL primary repair with suture augmentation. Our preliminary unpublished data with 49 patients treated with this technique and a variety of concomitant ligamentous injury with average follow-up of 1.7 years showed no MCL repair failures. Four patients experienced more than 10° of flexion range of motion loss, and 3 had residual valgus laxity of grade 1 at 0° and 30° of flexion. Conclusion: Primary MCL repair provides a minimally invasive treatment option for medial laxity, while the suture augmentation allows for early range of motion. Furthermore, this approach avoids delayed definitive surgical intervention of concomitant ligamentous injuries in the setting of combined multi-ligamentous injuries.

Paper 36: Change in Humeral Anchor Position Significantly Affects Isometry in UCL Repair: A 3-Dimensional Computer Modeling Study

Objectives:Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. While previous literature has illustrated the importance of tunnel position on restoring graft isometry in UCL reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. Herein, we describe a 3-dimensional (3D) elbow model to measure and optimize anchor location during UCL repair.Methods:A 3D computer model of a human elbow joint was created using CT and MRI images from a single patient. The humeral and ulnar attachments of the UCL were plotted using three distinct methodologies: 1) geometric cloud mapping; 2) quantitative measurements as described by the anatomical studies by Camp et al1; and 3) Frangiamore et al2. A 3.5mm-diameter clockface was placed on each attachment site which allowed for simulation of 12 distinct, 1.75mm deviations in anchor position. The three elbow models were then ranged through 0-120 degrees of flexion at 10-degree increments, and the 3D distances were measured between the two ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and ligament lengths were again measured to evaluate changes in isometry. An independent t-test was performed to determine if there was a significant difference in isometry between the humeral or ulnar anchor deviations.Results:Using method 1, the UCL length at 90 degrees of elbow flexion was 26.8mm. This ligament underwent 13.6mm of total excursion for a 46.4% change in length throughout arc of motion. Method 2 produced a 19.3mm ligament that underwent 0.8mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5mm ligament that underwent 2.3mm of excursion for a 9.4% length change throughout arc. Identifying ligament footprints using the quantitative anatomical measurements as described by Camp et al1 and Frangiamore et al2 produced better ligament isometry through 120 degrees of flexion (ligament length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique (46.4% length change). Humeral anchor deviations produced a statistically significant increase in ligament excursion when compared to ulnar anchor deviations (p < 0.001).Conclusions:When performing UCL repair, small deviations in humeral anchor position may significantly influence graft and ligament isometry. Anchor position was most isometric while using the quantitative measurements as described in Camp et al1. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics.

Treatment of Medial Collateral Ligament Injury During Total Knee Arthroplasty With Internal Suture Brace Augmentation: A Cadaveric and Biomechanical Study

Intraoperative medial collateral ligament (MCL) injury during total knee arthroplasty (TKA) is a serious complication. External bracing and/or conversion to a constrained implant has previously been studied. The technique of using an internal high-strength suture brace to augment an MCL repair has been evaluated in the nonarthroplasty patient and could provide an alternate solution. The goal of this study was to determine whether MCL repair with internal suture bracing restores stability of the implanted knee joint. A robotic simulator completed laxity testing on 5 cadaveric knee specimens in 4 sequential phases: (1) intact knee, (2) after implantation with TKA, (3) after sectioning of the MCL, and (4) after MCL repair with suture brace augmentation. Laxity was compared between the different test phases throughout range of motion. Subsequently, the internal brace was tested to failure under valgus load. The MCL repair with internal bracing was effective at restoring laxity in varus-valgus, internal-external, and me-dial-lateral degrees of freedom through midflexion, with limited support at deeper flexion angles and in anterior-posterior laxity. Rotational laxity was not significantly different than intact knee laxity. Generally, medial-lateral translations were less and anterior-posterior translations were greater and were significantly different at 30° to 45° and 90°, respectively. The mean failure moment was 46.4±9.1 Nm, with the primary mode of failure being MCL repair. Primary MCL repair with internal bracing using a high-strength suture augment showed the potential to provide adequate stability and strength to correct MCL incompetence in TKA without the use of an external knee brace or constrained implants. [Orthopedics. 202x;4x(x):xx-xx.].

Knee Medial Collateral Ligament Augmentation With Bioinductive Scaffold: Surgical Technique and Indications

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee; however, only a minority of cases require surgical intervention. Classically, isolated grade I and II MCL injuries are treated nonoperatively whereas isolated grade III injuries may be treated with surgery. High-grade MCL injuries are frequently associated with concomitant knee ligamentous injuries, particularly the anterior cruciate ligament. Nonetheless, MCL repair or reconstruction is generally reserved for patients with persistent valgus instability after failed nonoperative management. Synthetic and biological implants are increasing in popularity to augment repairs and reconstructions for biomechanical reinforcement and promotion of the native healing response to hasten rehabilitation. The BioBrace (Biorez, New Haven, CT) is a bioinductive scaffold composed of highly porous type I collagen and bioresorbable poly(L-lactide) microfilaments, providing an environment for soft-tissue regeneration and mechanical support. The purpose of this article is to describe the surgical technique and relative indications for the BioBrace in knee MCL ligament repairs and reconstructions.