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The “Figure of Four” Reconstruction of the Medial Collateral Ligaments in the Setting of Anteromedial Rotatory Knee Instability Using a Single Autograft

ABSTRACT: The deep medial collateral ligament plays an important role in controlling tibial external rotation and restrain anterior translation of the medial tibial plateau. Despite being the basic lesion of anteromedial knee instability as proposed by many authors, the majority of the medial side reconstructions do not restore the anatomy and the function of the deep medial collateral ligament. In this Technical Note, we describe a technique to reconstruct both the superficial and deep medial collateral ligament in the setting of anteromedial knee instability using a single peroneus longus autograft. Technique Video Video 1 The “figure of 4” reconstruction of both the superficial and deep medial collateral ligament using a single peroneus longus autograft. The graft is docked and fixed first to the deep medial collateral ligament femoral socket, and then passed distally and shuttled through a tibial transosseous tunnel from posterior to anterior to reproduce the deep medial collateral ligament tibial broad attachment. The free end of the graft is brought back proximally and fixed to the medial epicondyle by a staple at the superficial medial collateral ligament femoral insertion. Finally, the free end of the graft is shuttled into a tibial tunnel created 6 cm distal to the joint line and fixed to reconstruct the superficial part of the ligament.

SUBMITTER: Helal A

PROVIDER: S-EPMC9353192 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

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Project description:BackgroundNew 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.PurposeTo 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 designControlled laboratory study.MethodsEight 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.ResultsCutting 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).ConclusionIn 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 relevanceIn 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.

Project description:BackgroundAlthough a medial collateral ligament (MCL) injury is associated with anteromedial rotatory instability (AMRI) and often with an anterior cruciate ligament (ACL) injury, there has been little work to develop anteromedial (AM) reconstruction to address this laxity.PurposeTo measure the ability of a novel "anatomic" AM reconstruction technique to restore native knee laxity for isolated AM insufficiency and combined AM plus posteromedial insufficiency.Study designControlled laboratory study.MethodsA total of 12 cadaveric knees were mounted in a kinematic testing rig that allowed the tibia to be loaded while the knee flexed-extended 0° to 100° with 88-N anteroposterior translation, 5-N·m internal rotation-external rotation (ER), 8-N·m valgus, and combined anterior translation plus ER to simulate AMRI. Joint motion was measured using optical trackers with the knee intact, after superficial MCL (sMCL) and deep MCL (dMCL) transection, and after AM reconstruction of the sMCL and dMCL with semitendinosus autografts. The posteromedial capsule (PMC)/posterior oblique ligament (POL) was then transected to induce a grade 3 medial injury, and kinematic measurements were repeated afterward and again after removing the grafts. Laxity changes were examined using repeated-measures analysis of variance and post-testing.ResultssMCL and dMCL deficiency increased valgus, ER, and AMRI laxities. These laxities did not differ from native values after AM reconstruction. Additional PMC/POL deficiency did not increase these laxities significantly but did increase internal rotation laxity near knee extension; this was not controlled by AM reconstruction.ConclusionAM reconstruction eliminated AMRI after transection of the dMCL and sMCL, and also eliminated AMRI after additional PMC/POL transection.Clinical relevanceMany MCL injuries occur in combination with ACL injuries, causing AMRI. These injuries may rupture the AM capsule and dMCL. Unaddressed MCL deficiency leads to an increased ACL reconstruction failure rate. A dMCL construct oriented anterodistally across the medial joint line, along with an sMCL graft, can restore native knee ER laxity. PMC/POL lesions did not contribute to AMRI.

Project description:BackgroundInjuries of the superficial medial collateral ligament (sMCL) and anteromedial structures of the knee result in excess valgus rotation and external tibial rotation (ER) as well as tibial translation.PurposeTo evaluate a flat reconstruction of the sMCL and anteromedial structures in restoring knee kinematics in the combined MCL- and anteromedial-deficient knee.Study designControlled laboratory study.MethodsEight cadaveric knee specimens were tested in a 6 degrees of freedom robotic test setup. Force-controlled clinical laxity tests were performed with 200 N of axial compression in 0°, 30°, 60°, and 90° of flexion: 8 N·m valgus torque, 5 N·m ER torque, 89 N anterior tibial translation (ATT) force, and an anteromedial drawer test consisting of 89 N ATT force under 5 N·m ER torque. After determining the native knee kinematics, we transected the sMCL, followed by the deep medial collateral ligament (dMCL). Subsequently, a flat reconstruction of the sMCL with anteromedial limb, mimicking the function of the anteromedial corner, was performed. Mixed linear models were used for statistical analysis (P < .05).ResultsCutting of the sMCL led to statistically significant increases in laxity regarding valgus rotation, ER, and anteromedial translation in all tested flexion angles (P < .05). ATT was significantly increased in all flexion angles but not at 60° after cutting of the sMCL. A combined instability of the sMCL and dMCL led to further increased knee laxity in all tested kinematics and flexion angles (P < .05). After reconstruction, the knee kinematics were not significantly different from those of the native state.ConclusionInsufficiency of the sMCL and dMCL led to excess valgus rotation, ER, ATT, and anteromedial tibial translation. A combined flat reconstruction of the sMCL and the anteromedial aspect restored this excess laxity to values not significantly different from those of the native knee.Clinical relevanceThe presented reconstruction might lead to favorable results for patients with MCL and anteromedial injuries with an anteromedial rotatory knee instability.

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The “Figure of Four” Reconstruction of the Medial Collateral Ligaments in the Setting of Anteromedial Rotatory Knee Instability Using a Single Autograft

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