Superficial and Deep Medial Collateral Ligament Reconstruction for Chronic Medial Instability of the Knee.
ABSTRACT: There are several surgical techniques for medial collateral ligament reconstruction, including anatomic or nonanatomic medial knee reconstruction. Although the medial collateral ligament consists of the superficial medial collateral ligament (sMCL) and deep medial collateral ligament (dMCL), surgical procedures have only been described for reconstruction of the sMCL alone or reconstruction of the sMCL and posterior oblique ligament. The dMCL assists the knee in rotational stability, primarily in extension, moving into early flexion. We describe sMCL and dMCL reconstruction with semitendinosus and gracilis autografts using adjustable-length loop suspensory fixation devices for tibial fixation. By use of our technique, it is possible to provide good stability and satisfactory results for medial instability of the knee.
Project description:This report describes superficial medial collateral ligament reconstruction of the knee using a novel method of graft fixation with the ACL Tightrope RT (Arthrex, Naples, FL). After tibial fixation with either a standard interference screw or staple, femoral fixation of the semitendinosus tendon is performed with the adjustable-loop suspensory fixation device, which allows for both initial graft tensioning and re-tensioning after cyclical knee range of motion. This provides the ability for the graft to accommodate for resultant soft-tissue creep and stress relaxation, thereby allowing for optimal soft-tissue tension and reduction in laxity at the end of the procedure.
Project description:The exclusive autograft choice for medial collateral ligament (MCL) reconstruction that has been described until today is the semitendinosus tendon. However, this has some potential disadvantages in a knee with combined MCL-anterior cruciate ligament (ACL) injury, including weakening of the hamstring's anterior restraining action in an already ACL-injured knee and nonanatomic distal MCL graft insertion when leaving the semitendinosus insertion intact at the pes anserinus during reconstruction. Moreover, because some surgeons prefer to use the hamstring for autologous ACL reconstruction, the contralateral uninjured knee hamstring needs to be harvested as a graft source for the MCL reconstruction if autografts and not allografts are the surgeons' preference. We describe a technique for performing combined reconstruction of the MCL and ACL using ipsilateral quadriceps tendon-bone and bone-patellar tendon-bone autografts. This technique of MCL reconstruction spares the hamstring tendons and benefits from the advantage provided by bone-to-bone healing on the femur with distal and proximal MCL tibial fixation that closely reproduces the native MCL tibia insertion.
Project description:The superficial medial collateral ligament (sMCL) and associated knee structures are the most commonly injured structures of the knee. Most isolated sMCL tears are treated nonoperatively. Several studies have described different algorithms for treatment of sMCL lesions, as well as different types of techniques, both in the acute and in chronic settings. The purpose of this article was to detail our anatomic sMCL augmentation technique using semitendinosus and gracilis tendon autografts.
Project description:High tibial osteotomy (HTO) is a commonly performed surgical procedure. Although it is well-known that the superficial medial collateral ligament (sMCL) should be released during HTO, there is still no agreement on performing its reattachment. Considering the function of the sMCL, after its release during HTO, increased medial joint instability may be expected. We present a technique for sMCL reattachment that prevents medial gapping development and maintains nearly native pressure on the medial compartment of the knee joint by matching the tension on the sMCL to the size of the osteotomy gap. This technique is suitable for any correction angle.
Project description:Pie-crusting technique is a damage-control soft tissue balance skill of total knee arthroplasty (TKA). The outcome of this technique to release lateral soft tissue is reasonable. A limited number of studies have focused on medial collateral ligament release with pie-crusting technique in the past years because of concerns about its efficacy and safety.All cases underwent superficial medial collateral ligament (SMCL) release with either pie-crusting technique or traditional technique (39 knees in each group) between January 1, 2014 and August 31, 2015. A comparison study between two techniques was performed; meanwhile, 23 patients (26 knees) in pie-crusting group were followed up. Data including knee function, radiographic result and complications were analysed.Comparison study demonstrates that pie-crusting technique can achieve a comparable or even better effect of alignment correction. Data of follow-up patients are reasonable. The mean postoperative flexion contracture is 1.2 ± 3.6°. The mean postoperative motion arrange is 104.0 ± 14.4°. The mean postoperative hospital for special surgery knee score point is 82.0 ± 7.4 points. The mean postoperative femoral tibial angle is 172.4 ± 2.0°. The level of joint line elevates around 2.1 ± 1.9 mm. There are four knees that use brace after operation, and none of them present unstable knee. No severe complication has been reported, and most patients were satisfied with life quality.Using pie-crusting technique to release SMCL for TKA is effective and safe.Although pie-crusting technique has been used in TKA for years, it is seldom chosen to release medial collateral ligament, especially to release SMCL, which is a vital step of malalignment correction. This study aims to evaluate the efficacy and safety of this technique in total knee arthroplasty patients.
Project description:The aim of this study was to quantify the medial soft tissue contributions to stability following constrained condylar (CC) total knee arthroplasty (TKA) and determine whether a medial reconstruction could restore stability to a soft tissue-deficient, CC-TKA knee.Eight cadaveric knees were mounted in a robotic system and tested at 0°, 30°, 60°, and 90° of flexion with ±50 N anterior-posterior force, ±8 Nm varus-valgus, and ±5 Nm internal-external torque. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were transected and their relative contributions to stabilising the applied loads were quantified. After complete medial soft tissue transection, a reconstruction using a semitendinosus tendon graft was performed, and the effect on kinematic behaviour under equivocal conditions was measured.In the CC-TKA knee, the sMCL was the major medial restraint in anterior drawer, internal-external, and valgus rotation. No significant differences were found between the rotational laxities of the reconstructed knee to the pre-deficient state for the arc of motion examined. The relative contribution of the reconstruction was higher in valgus rotation at 60° than the sMCL; otherwise, the contribution of the reconstruction was similar to that of the sMCL.There is contention whether a CC-TKA can function with medial deficiency or more constraint is required. This work has shown that a CC-TKA may not provide enough stability with an absent sMCL. However, in such cases, combining the CC-TKA with a medial soft tissue reconstruction may be considered as an alternative to a hinged implant.
Project description:PURPOSE:This study evaluated the medial joint stability after high tibial osteotomy (HTO) releasing the superficial medial collateral ligament (sMCL) without cutting and repairing. METHODS:Twenty-one patients who performed HTO were enrolled. After an L-shaped incision was made in the pes anserinus, the sMCL was released from the distal portion during surgery. After plate fixation, the sMCL was reattached and the pes anserinus was repaired underneath the plate. Plate removal was performed after 31.1?±?14.2?months. Before HTO, a valgus force of 40?N was exerted at extension for reference values. Before and after plate removal, a valgus force of 40?N was exerted at extension and at a flexion position of 20°. Medial stability was evaluated by measuring the joint line convergence angle (JLCA). RESULTS:The JLCAs in the extension state before HTO and plate removal were 1.64°?±?1.15° and 1.83°?±?1.36°, respectively; there was no significant difference (p?=?0.198). There was also no significant difference in JLCA before HTO and after plate removal (p?=?0.835). There was also no significant difference in JLCA before and after plate removal both at a knee extension and flexion position of 20° (p?=?0.348 and p?=?0.456, respectively). CONCLUSIONS:Releasing the sMCL without cutting and repairing the pes anserinus underneath the plate during medial open wedge HTO could facilitate the maintenance of medial joint stability.
Project description:Purpose:To systematically review the literature to better understand the technique, outcomes, and complications after percutaneous superficial medial collateral ligament (sMCL) lengthening during knee arthroscopy to address isolated medial meniscal pathology. Methods:A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. The inclusion criteria consisted of English-language articles or articles with English-language translations documenting the use of percutaneous sMCL lengthening during arthroscopic knee surgery to treat isolated meniscal pathology (repair vs meniscectomy) with reported postoperative outcomes and complications. Results:Four studies met the inclusion criteria, consisting of a total of 192 patients undergoing percutaneous sMCL lengthening. No perioperative complications related to iatrogenic chondral damage, fracture, or additional meniscal injury were reported. Mild postoperative pain at the medial needle tract site lasting up to 15 days after surgery was reported in 52% of patients (46 of 88). At final follow-up, laxity on valgus stress testing showed a range from 0 to 1.1 mm with a range from -0.3° to 0.9° of radiographic medial joint space widening compared with preoperative radiographs. The length of follow-up ranged from 1.5 to 24 months. Conclusions:The percutaneous "pie-crusting" technique remains the most commonly reported technique to lengthen the sMCL during arthroscopic meniscal surgery. Percutaneous lengthening represents a safe and effective method of increasing medial joint space visualization, with no reported perioperative or postoperative complications and with minimal, likely clinically insignificant residual joint laxity after surgery on valgus stress testing at final follow-up compared with preoperative values. Level of Evidence:Level IV, systematic review of Level IV studies.
Project description:Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are the most common type of combined ligamentous injury of the knee. The optimal treatment for these combined injuries is controversial. Combined ACL and MCL-posterior oblique ligament (POL) reconstruction avoids late anteromedial rotatory instability and chronic valgus instability of the knee and decreases the increased stress on the ACL graft. Graft choice (hamstring tendon autograft, quadriceps bone-patellar tendon-bone autograft, or Achilles tendon allograft) and anatomic restoration of the medial and posteromedial corner of the knee are challenges of this combined reconstruction. This article describes a technique that allows combined ACL and MCL-POL reconstruction. The hamstring tendons from the contralateral limb are tripled and used as the ACL graft. The gracilis tendon from the ipsilateral limb is doubled and used as the MCL-POL graft. The semitendinosus tendon of the ipsilateral limb is preserved. After ACL reconstruction, the MCL-POL graft is suspended on the ACL graft at the distal end of the tibial tunnel and the graft limbs are used for open reconstruction of the MCL and POL. Three interference screws (Arthrex, Naples, FL) and 1 metal staple are used for graft fixation of this combined reconstruction.
Project description:Injuries to the medial collateral ligament (MCL) and posteromedial corner can occur in isolation or in the setting of multiligamentous knee injuries. Reconstruction of the MCL and posteromedial corner is indicated in the setting of a multiligamentous knee injury. Isolated cases failing nonoperative treatment may also undergo surgical treatment. Our preferred technique for anatomic medial-sided knee reconstruction is an open anatomic MCL reconstruction using an Achilles tendon allograft along with direct repair of all associated medial and posteromedial structures.