Abstract
Background:
Nonsurgical treatment of concomitant medial collateral ligament (MCL) in the setting of anterior cruciate ligament reconstruction (ACLR) increases the risk of graft failure. Few published cases of medial complex reconstruction combined with ACLR with no clear consensus on the optimal technique to treat these complex injuries.
Indications:
A female patient aged 41 years, with failure of ACLR in 2009 and 2 revisions in 2013 and 2014, associated with concomitant nontreated MCL and posterior oblique ligament (POL) injury. Physical examination showed valgus test laxity grade III at 30° of knee flexion and at full extension, with Lachman and pivot-shift test grade III. Imaging showed normal long-leg standing axis with 10° posterior tibial slope on radiograph, and associated MCL and POL injury on magnetic resonance imaging.
Technique Description:
ACLR and anterolateral tenodesis using the fascia lata leaving its distal insertion on the Gerdy tubercle, with double-stranded contralateral gracilis, was completed. A new femoral tunnel was made from outside to inside, with preservation of the previous tibial tunnel. The transplant was fixed with 2 interference screws. Second, the contralateral semitendinous autograft was used for MCL and POL reconstruction. A single strand of the graft was used for femoral fixation created on femoral epicondyle to cover MCL and POL origins, and double strands were used for distal fixation of MCL at the level of hamstring insertion and POL at the posteromedial corner of medial tibial plateau. The graft was secured with 3 interference screws at 30 knee flexion for MCL and full extension for POL.
Results:
The results include favorable functional and clinical outcome with improvement in the anteroposterior and rotatory knee stability at mid-term follow-up. Lateral extra-articular tenodesis in supplementing ACLR controls internal tibial rotatory knee stability. Double-bundle reconstruction of MCL and POL improved both valgus and anteromedial rotatory instability by restraining external rotation.
Discussion/Conclusion:
Surgeons should consider the need for surgical treatment of concomitant MCL injury to prevent chronic valgus laxity and increased strain on the anterior cruciate ligament (ACL) graft, potentially increasing the risk of ACLR revision. Our described technique offers a safe method for ACLR and lateral tenodesis with an advantage to avoid tunnel convergence, and medial stabilization to restore native valgus and rotatory stability and prevent increased stress on ACL graft.
This is a visual representation of the abstract.
Video Transcript
Hello, my name is Etienne Cavaignac. I want to describe an original technique for the revision of a failed anterior cruciate ligament (ACL) reconstruction combined with reconstruction of the knee’s medial complex. Here are my disclosures.
Not treating coexisting medial collateral ligament (MCL) and posterior oblique ligament (POL) tears in the setting of ACL reconstruction increases the risk of graft failure. There are few publications on medial complex reconstruction combined with revision of a failed ACL reconstruction. Consequently, there is no clear consensus on the optimal technique for treating these complex injuries.
It is important to have a good understanding of the medial complex, which includes the MCL and the POL. The MCL contributes to stability in valgus, while the POL contributes to stability in rotation. Note that the deep bundle of the MCL is located under the MCL, thus provides control over valgus. A good understanding of this anatomy is critical to developing a surgical technique that counters both the valgus stresses with the MCL and the rotational stresses with the POL. Our preferred technique in this situation is the Lind technique.
There are several advantages of the outside-in ACL revision technique, which uses the iliotibial band (ITB) and gracilis tendon as grafts. Anterior cruciate ligament reconstruction and lateral tenodesis can be performed simultaneously. The ITB graft’s distal attachment is left intact and the graft is continuous. Drilling the femoral tunnel using an outside-in technique minimizes the risk of tunnel overlap. Doing a single-stage revision saves time and avoids the risks and morbidity of a 2-stage revision.
The first objective of this video is to describe a technique for ACL revision using an ITB autograft. The second objective is to describe a technique for simultaneous reconstruction of the knee’s medial complex.
Our case study features a 41-year-old female patient who is very athletic and participates in rugby, judo, and hiking. Her main complaint is a feeling of medial instability or giving out during weightbearing on her right knee. In her history, we see that she underwent ACL reconstruction in her right knee in 2009 with a hamstring graft. She underwent revision ACL surgery in 2013 with the bone–patellar tendon–bone (BPTB). She needed another revision on this knee in 2014, which was done by a contralateral BPTB combined with lateral tenodesis using the ITB. Remember that her chief complaint is the valgus laxity in her right knee that has been present since her first knee injury in 2009.
We start the clinical examination on the contralateral side. We find no laxity in the frontal plane in full extension or in 30° flexion. When we look at her right knee, we find valgus laxity in full extension and in 30° flexion. The ACL is also not normal, with a positive Lachman test and a grade II pivot shift.
Let us focus next on the preoperative imaging. On these x-rays, there are no signs of osteoarthritis and there is no evidence of osteolysis or widening in the tunnels. On a long-leg standing view, we find a tibial slope of 10°, which is at the upper end of normal, and normal alignment of the lower limb. A magnetic resonance imaging (MRI) of the first injury in 2009 shows an ACL tear combined with a grade II MCL tear and damage to the posteromedial corner, particularly the POL. A recent MRI confirms that the ACL graft is torn and that the MCL and POL have not healed. There is no evidence of meniscal or osteochondral lesions.
She is a young athletic patient who has instability in the frontal and sagittal planes. This is an indication for another ACL revision combined with lateral tenodesis. Because the tibial tunnel is in good position, it will be reused. The femoral tunnel, in our opinion, is a bit too proximal. So, we will make another one using the outside-in drilling technique.
Our graft of choice for this procedure is the ITB, which can also be used for lateral tenodesis. Although it has already been used, this is not a contraindication. In this case, we will also harvest a contralateral hamstring graft to do the following: reinforce our ITB graft and carry out reconstruction of the medial complex.
Fixation will be achieved with 2 interference screws. The medial complex will be reconstructed with the contralateral hamstring graft to treat the rotational and valgus laxity that the patient has felt.
Let us start by the technique for revision ACL reconstruction. The patient is supine. A foot roll is used to place the knee in about 90° flexion and a lateral post at the thigh. We will reuse the existing lateral incision.
The first step consists of harvesting the ITB, which will be collected through an incision on the posterior edge, while preserving the posterior portion of the fascia lata to allow it to be reclosed. Next, an anterior incision is made that defines a triangular shape for the graft, with a proximal tip and distal base over Gerdy’s tubercle. About 1 cm of graft should stay connected where it inserts on Gerdy’s tubercle. It is important to transect the intermuscular septum, as this will make it easier to reclose the fascia lata laterally.
The isometric point that is proximal to the lateral femoral condyle is located and marked with an electrocautery tip. This is the external landmark for the new femoral tunnel. The graft is prepared by incorporating the contralateral gracilis folded in two. It is secured to the graft with size 0 suture, and then the graft is augmented with an internal brace. The graft is then measured. Here the diameter is 8 mm, while the length is around 15 cm.
The first step is drilling a femoral tunnel with an outside-in aiming device. Inside the joint, we locate the ligament’s footprint and then place the external slider over the isometric point mentioned previously. Drilling starts with a 5-mm-diameter bit and is increased gradually until we match the size of the graft, which is 8 mm here. As for the tibial tunnel, we decided to reuse the existing tibial tunnel. It is drilled starting with a 5-mm bit and then increased gradually until 8 mm.
You can see here that drilling an outside-in femoral tunnel did not cause any convergence. We then check that the tunnel is complete and that the cortical edge has been completely decorticated. We perform the same checks on the tibial side. The graft is then passed from proximal to distal. We carefully insert the guide pin before pulling the graft through. The femoral fixation is done first and then the tibial one using interference screws.
The next step is the medial reconstruction. The first step is to make an incision over the MCL. It is opened longitudinally to be able to position the graft. At the same time, we make a posterior window to make room for the graft for the posteromedial corner. We need to locate the joint line to make sure we do not enter the joint and that we are below it. The tibial tunnel for the POL is made using a conventional aimer. A 6-mm tunnel is drilled, and a relay suture added.
We then focus on the MCL. A socket is made just below the medial femoral condyle. Because we are using a contralateral hamstring graft, we had to make a tibial tunnel at the level of the distal insertion of the MCL. This is the first point that we secure with a 6-mm-diameter interference screw. We then determine the length of graft needed for the MCL reconstruction while keeping at least 15 mm of graft inside the recess. The graft is then prepared and passed into the socket. The graft is introduced with maximum tension on it. It is secured with an interference screw with the knee in 30° flexion and as much varus as possible.
The POL reconstruction is done next using the free limb of the graft, which is passed through the window made for this purpose and then into the anteroposterior tunnel in the tibia. The graft is secured with an interference screw, which is inserted from anterior to posterior with the knee in full extension, placing as much traction on it as possible. The screw is inserted until it grazes the tibial tunnel posteriorly. We add an anchor, as close as possible to the joint line to secure the graft. The aim is to reconstruct the deep bundle of the MCL. This prevents a windshield wiper effect of the graft on the tibial plateau. Immediate testing finds a rigid fixation.
On postoperative x-rays, we can see the different tunnels that have been made: the tibial tunnel is reused for the ACL reconstruction, a new outside-in femoral tunnel was made, with no convergence, and new tunnels were made for the medial reconstruction using the MCL and POL graft.
The potential complications for this type of procedure are tunnel convergence, which is minimized by using the outside-in drilling technique. This risk of incorrect tunnel positioning is also minimized by using outside-in drilling. Knee stiffness is a problem that can be solved with an appropriate rehabilitation protocol. The ACL graft could rupture again if the medial laxity is not addressed.
In our rehabilitation protocol, during the first 3 weeks postoperatively, the patient is allowed touch-down weightbearing with an extension splint. From week 3 to 6, the patient wears an articulated splint with flexion up to 30°. Weightbearing is gradually increased over 3 weeks. At 6 weeks, full weightbearing is allowed along with flexion beyond 90°. After 3 months, full weightbearing continues and splint use is discontinued.
The desired outcomes are functional improvement with a stable knee and return to sports. The range of motion must be 0 to 130°. Overall, the functional outcomes are only slightly worse to those of primary ACL reconstruction.
Here is the patient at the 3-month follow-up visit. There is no laxity in extension or flexion, the Lachman has a firm endpoint, and the pivot shift is negative during the clinical examination.
Keep in mind that: medial lesions do not always heal!
Footnotes
Submitted February 5, 2021; accepted February 12, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: E.C. is a paid consultant for Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.