Abstract
Background:
Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries and, when they occur in isolation, they often progress with satisfactory outcomes using conservative treatment. However, MCL lesions associated with anterior cruciate ligament or posterior cruciate ligament (PCL) injuries in knee dislocations should be reconstructed to prevent failure of the central pivot. In knees with combined injuries involving the PCL and the MCL, the confluence of tunnels in the medial femoral condyle can be a potential problem during reconstruction surgery.
Indications:
The indication of this technique is the combined injury of the PCL and the MCL.
Technique Description:
The technique consists in the reconstruction of the PCL and the MCL with an Achilles tendon allograft. The bone plug of the graft is fixed on the tibial bed with the inlay technique. The graft passes through a single femoral tunnel drilled in the medial femoral condyle, with entrance point on the footprint of the PCL on the inner wall of the condyle and exit on the origin of the native MCL, near to the medial epicondyle. The graft is fixed in the femoral tunnel with an interference screw and continues to the isometric point of the anatomic insertion of the MCL in the tibia, where an interference screw is used to fix it.
Results:
Results from our group using this technique have shown good clinical outcomes, with complications and failure rates similar to other series in the literature.
Discussion/Conclusion:
This technique is an excellent option for surgeons, when an Achilles tendon allograft is available, to avoid confluence of tunnels in the medial femoral condyle. It presents good results and acceptable complication rates, compatible with the severity of this lesion.
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.
This is a visual representation of the abstract.
Video Transcript
Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries and, when they occur in isolation, they often progress with satisfactory outcomes using conservative treatment. However, lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot. In combined injuries involving the PCL and the MCL, the confluence of tunnels in the medial femoral condyle can be a potential problem during reconstruction surgery.
The technique presented in this video proposes the associated reconstruction of the PCL and the MCL with a single combined tunnel in the medial femoral condyle. 1 The patient presented is a man who suffered a torsional trauma to the left knee, progressing with significant knee instability. On physical examination, he has a positive posterior drawer test and a positive valgus stress test.
The indication of this technique is the combined injury of the PCL and the MCL. The contraindication is the unavailability of an Achilles tendon allograft or tissue bank. The technique consists in the reconstruction of the PCL and the MCL with an Achilles tendon allograft. The bone plug of the graft is fixated on tibial bed as inlay technique and the graft passes through a single femoral tunnel drilled in the medial femoral condyle, with entrance point on the footprint of the PCL on the inner wall of the condyle and exit on the origin of the native MCL, near to the medial epicondyle. The graft is fixed in the femoral tunnel with an interference screw and continues to the isometric point of the anatomic insertion of the MCL in the tibia, where an interference screw is used to fix it.
The patient is placed in supine position on a radiolucent table. A single frozen Achilles tendon allograft is prepared, including the bone block containing the tendon insertion. The bone block is sectioned to achieve a thickness of 1.5 cm, length of 1.5 cm, and depth of 1.0 cm, and a 4.5-mm tunnel is drilled in the center for the passage of the fixation screw. The tendinous part of the graft is regularized and tubularized, allowing passage through a 10- or 11-mm diameter tunnel.
A posteromedial approach is made to the knee, with an incision starting in the medial femoral epicondyle and proceeding to the posteromedial border of the tibia. The sartorial fascia is opened, allowing dislocation of the semitendinosus and gracilis tendons. After that, the popliteus muscle is detached from the posterior region of the tibia. Then, the medial epicondyle is identified.
Fluoroscopy can be used to check the MCL origin point in the femur, just posterior and proximal to the medial epicondyle. A guide wire is passed at this point, and the drill is inserted 0.5 cm to mark the insertion point of the MCL on the femur. After that, arthroscopy is initiated, and a joint inspection is performed. The large widening of the medial articular space denotes MCL and associated central pivot injury.
The outside-in femoral guide is introduced through the anteromedial portal and positioned in the PCL footprint. Externally, the guide is placed in the previously drilled point of the MCL origin. We place the guide wire in the most anterior and distal region of the PCL footprint, to reconstruct the anterolateral bundle. The position of the guidewire is checked, and the tunnel is drilled to the measured width of the graft.
Then, a bone bed is constructed using a curved osteotome in the posterior region of the tibia, approximately 1.5 cm distal to the end of the posterior tibial plateau. A Mixter forceps is inserted through the arthroscopic portal, passing through the joint capsule, and an Ethibond 5 (Ethicon Inc.) is pulled into the joint. Then, the Ethibond is pulled through the femoral tunnel and will serve to guide the passage of the graft. The graft is passed from the posterior region of the tibia toward the femur. Tibial fixation is performed using a 6.5-mm cancellous screw with a washer, passing through the hole previously made in the bone graft block.
After tibial fixation, movement of the graft during the posterior drawer test shows that the tunnel is well positioned and stabilization will be satisfactory. The graft is fixed in the femoral tunnel with an interference screw with the same diameter of the tunnel, with the knee positioned at 90° of flexion, and the tibia reduced.
Then, the MCL insertion point is located on the tibia, approximately 6 cm below the joint line. At the most isometric point, the tibial tunnel of the MCL is drilled with the same diameter as the femoral tunnel. The graft is positioned in the tibial tunnel, and then tensioned and fixed with an interference screw, with the knee in 30° of flexion and varus force being applied. Finally, the advancement of the posteromedial structures is performed, and the wound is sutured by layers.
As a potential complication, we have possible difficulty in passing the inlay screw through the posteromedial access, which may become intra-articular. To avoid problems with that, we should have proper exposure and verify screw position with fluoroscopy. Another potential problem is a difficult fixation of the large-diameter graft of the MCL in the cortical bone of the tibia. To avoid that, tapping may be necessary prior to the passage of the graft on the tibial tunnel, and the interference screw should not be larger than the tunnel for the tibial fixation. Finally, the branches of the saphenous nerve must be identified and protected during subcutaneous dissection to avoid injuries.
After surgery, patients are kept with a knee brace in extension for the first 3 weeks, with partial weightbearing and no range of motion allowed. From weeks 4 to 6, patients begin protected passive range of motion exercises in the prone position. From the seventh week, the knee immobilizer is discontinued, and active range of motion and weightbearing are allowed as tolerated. The return to full activity happens between 9 and 12 months after surgery.
In our series, we have 13 patients with a minimum follow-up of 2 years. Three patients had loss of extension (3° in 1 patient and 5° in 2 patients); 8 patients had loss of flexion (varying between 5° and 30°); 2 patients had superficial wound infection, treated with oral antibiotics with good outcomes; and 3 patients had failure of the ligament reconstruction (2 in the PCL, 1 in the MCL). The mean International Knee Documentation Committee (IKDC) subjective score was 71.6 ± 16.2, the mean Lysholm score was 80.1 ± 13.9, and the median Tegner score was 6, ranging from 2 to 7. For the Objective IKDC scale, we had 4 patients scoring A, 6 patients scoring B, and 3 patients scoring C; no patient had a D score.
This was the reference for this video. Thank you.
Footnotes
Submitted June 10, 2023; accepted July 27, 2023.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.