Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability

Wierer, Guido; Kittl, Christoph; Fink, Christian; Weiler, Andreas

doi:10.1016/j.eats.2022.03.034

Cited by 12 publications

(8 citation statements)

References 33 publications

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“…Several techniques have been proposed in recent years to address persistent rotatory instability after conventional MCLR. 18,20,40 To the authors' knowledge, 2 constructs have achieved valgus and rotatory stability in the setting of sMCL and dMCL injuries-both utilizing an sMCL limb and an anteromedial or dMCL limb. The first construct, described by Miyaji et al, 26 used a dMCL construct placed in the same position as the current study.…”

Section: Discussionmentioning

confidence: 99%

“…The lack of attention to rotatory stability is reflected in the multitude of surgical reconstruction techniques that have been developed to restore valgus stability, 10,18,21,24,46 usually with a superficial medial collateral ligament (sMCL) limb, while only recently have reconstructions included a deep MCL (dMCL) limb to restore rotatory stability. 5,20,26,40 While the MCL is the most injured ligament of the knee, surgical techniques for its repair and reconstruction have received less attention than the cruciate ligaments and the posterolateral corner, likely as a result of its excellent healing potential in the isolated setting. 8,12,13,25,29,31,38 This has begun to change, as multiple recent studies have highlighted the increased anterior cruciate ligament (ACL) rerupture rate if medial-sided instability is not addressed at the time of ACL reconstruction (ACLR), likely due to increased forces on the ACL graft.…”

Section: -In-5mentioning

confidence: 99%

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confidence: 99%

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Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Borque,

Han,

Dunbar

et al. 2024

Am J Sports Med

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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.

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Section: Discussionmentioning

confidence: 99%

Section: -In-5mentioning

confidence: 99%

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Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Borque,

Han,

Dunbar

et al. 2024

Am J Sports Med

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“…Im Gegensatz zur Valgusaufklappbarkeit ist eine Rotationsinstabilität im akuten Setting nur schwer zu beurteilen und fließt, außer in offensichtlichen Fällen, nicht in die Operationsindikationsstellung ein. In der Arthroskopie kann sich diese in einem vergrößertem Dreieck der anteromedialen Kapsel darstellen; dies bestätigt auch die frühzeitige operative Versorgung [ 39 ]. Dieses, im Vergleich zur medialen Rekonstruktion bei verbleibenden chronischen Instabilitäten, einfache Vorgehen soll einer chronischen medialen Instabilität vorbeugen.…”

Section: Therapieunclassified

“…Die Erkenntnisse befinden sich derzeit, aufgrund neuer biomechanischer Erkenntnisse, die das POL nicht mehr als Hauptstabilisator der AMRI und medialen Instabilität beschreiben, im Wandel. Dieser Wandel führt dazu, dass die derzeitigen Rekonstruktionen versuchen, neben der Valgusinstabilität auch eine anteromediale Instabilität zu hemmen ([ 1 , 30 , 39 ]; Abb. 4 ).…”

Section: Therapieunclassified

Verletzungen des medialen Bandapparats des Kniegelenks

Herbst,

Glasbrenner,

Deichsel

et al. 2023

Unfallchirurgie

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ZusammenfassungVerschiedene mediale Strukturen sind für die Hemmung der Valgus‑, Außenrotations- und anteromedialen Rotation zuständig. Aus Verletzungen dieser Strukturen können unterschiedlich ausgeprägte isolierte und kombinierte Instabilitäten resultieren. Das hintere Schrägband („posterior oblique ligament“, POL) wird, im Gegensatz zu früheren Spekulationen, nicht mehr als Hauptstabilisator der anteromedialen Rotationsinstabilität (AMRI) angesehen. Die akuten proximalen medialen Rupturen sind die Domäne der konservativen Therapie, mit sehr guten klinischen Ergebnissen. Im Gegensatz dazu bedingen akute distale Rupturen meistens ein operatives Vorgehen. Chronische Instabilitäten treten überwiegend in Kombination mit Instabilitäten des vorderen Kreuzbands (VKB) auf. Die klinische Untersuchung ist speziell bei diesen Instabilitäten ein wichtiger Bestandteil zur Indikationsstellung einer Operation für eine zusätzliche mediale Rekonstruktion. Bei hochgradigen medialen und anteromedialen Instabilitäten sollte an eine operative Versorgung gedacht werden. Biomechanisch erscheint eine kombinierte mediale und anteromediale Rekonstruktion den anderen Rekonstruktionsarten überlegen. Derzeit fehlen klinische Studien, um genau diesen biomechanischen Vorteil auch klinisch zu belegen.

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MCL augmentation using a peroneus longus split tendon autograft satisfactorily restores knee stability with no impairment in foot function and with a low failure rate for concurrent ACL reconstruction

Hinz,

Müller,

Eggeling

et al. 2024

Knee surg. sports traumatol. arthrosc.

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PurposeAddressing grade 2 and 3 medial‐sided instabilities during anterior cruciate ligament (ACL) reconstruction is crucial to reduce the risk of ACL graft failure. This study introduced a minimally invasive, medial collateral ligament (MCL) augmentation technique using a peroneus longus split tendon autograft, which was fixed to the femoral deep MCL insertion and tibial superficial MCL insertion.MethodsThis prospective, longitudinal, single‐centre case series included patients who underwent MCL augmentation concurrent with primary or revision ACL reconstruction due to anteromedial instability. Preoperatively and at 1‐year follow‐up, clinical examinations, such as rolimeter test of anterior tibial translation and medial instability, knee (International Knee Documentation Committee subjective knee form [IKDC], Lsyholm, Knee Injury and Osteoarthritis Outcome Score [KOOS]) and foot function scores (American Orthopaedic Foot and Ankle Society score [AOFAS]) and complications, were analyzed.ResultsThirty‐one patients with a mean follow‐up of 13.5 ± 2.6 months and a mean age of 27.8 ± 9.6 years were included. The side‐to‐side difference for anterior tibial translation significantly improved from preoperative to 1‐year follow‐up with an ACL reconstruction failure rate of 6.5%. No patient retained a grade 2 or 3 medial instability on valgus stress testing with 30° flexion. Significant improvements from preoperative to 1‐year postoperative follow‐up were observed in knee function scores: IKDC (48.9 ± 26.9– 71.3 ± 11.5, p < 0.001) and Lysholm (59.9 ± 28.5–80.5 ± 11.2, p = 0.002) as well as KOOS pain, ADL, sport and QoL, each reaching the respective minimal clinically important difference values. The foot function score AOFAS showed no significant impairment (100 ± 0–99.3 ± 2.5, p = 0.250). Complications included cyclops lesions of ACL reconstruction in three patients.ConclusionAt 1‐year follow‐up, MCL augmentation using a peroneus longus split tendon autograft for patients simultaneously undergoing ACL reconstruction satisfactorily restores knee stability, has a low ACL reconstruction failure rate and does not significantly impair foot function.Level of EvidenceLevel IV therapeutic study; case series.

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Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability

Cited by 12 publications

References 33 publications

Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Verletzungen des medialen Bandapparats des Kniegelenks

MCL augmentation using a peroneus longus split tendon autograft satisfactorily restores knee stability with no impairment in foot function and with a low failure rate for concurrent ACL reconstruction

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