Weave Technique for Reconstruction of Medial Collateral Ligament and Posterior Oblique Ligament: A Functional Percutaneous Approach Using Gracilis Tendon

Abstract

Background:

Injury to the medial collateral ligament (MCL) is common. MCL injuries, with impairment of its superficial portion, associated with the deep portion, lead to valgus instability and extrusion of the medial meniscus, resulting in instability and increased pressure in the medial compartment, with consequent damage to the cartilage. We can synthesize this set of structures as the medial meniscocapsular complex. Treating medial, superficial, and deep capsular meniscal complex together aims to restore the normal anatomy, stability, and function of the medial meniscus.

Indications:

• Anterior cruciate ligament with MCL grade III or MCL grade II

• MCL grade III or grade II with clinical instability

Technique Description:

An arthroscopic examination was performed to assess the “floating meniscus” sign and to confirm a tear of the MCL. The gracilis tendon is harvested in a usual fashion, leaving its distal insertion pedicle fixed to the tibial bone. An incision over the medial epicondyle is made, and a 6-mm drill is used to create a 2.5-cm bone tunnel. The passage of the medial subfascial graft is made toward the medial epicondyle. At this point, its fixation is performed with an interference screw. After fixing the anterior arm, we will return with the free portion of the graft in the most posterior portion and also percutaneously. This posterior arm is biologically fixed, closing the sartorius fascia over the 2 arms of the reconstruction with periosteal stitches.

Results:

Reconstruction tests were performed on cadaver models, obtaining a graft tension without compromising the range of motion (ROM) and a good result in their final analysis. We ended up publishing our results in a clinical study, with good functional results in both the Lysholm and Tegner scores, at a follow-up of 2 years.

Discussion/Conclusion:

We present an arthroscopic-assisted technique for a medial, percutaneous, aesthetic, and extremely functional approach. A technical limitation of our procedure is the absence of a biomechanical test for the gracilis double reconstruction: a strong point is that we performed some reconstruction tests on cadaver models, obtained good visual results and graft tension without compromising the ROM, and performed a positive clinical study with a minimum follow-up of 2 years. In conclusion, a simple and inexpensive technique that uses known anatomic principles of graft placement, without compromising ROM was performed.

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.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

We call this technique the Weave technique for reconstruction of the medial collateral ligament (MCL) and posterior oblique ligament (POL): a functional percutaneous approach using gracilis tendon, step by step. My name is Luis Fernando Z. Funchal, I represent Baia Sul Medical Center, Florianópolis, Santa Catarina, Brazil. We do not have disclosures for this video.

Video Overview: During this video, we are going to present the history and the examination, imaging, management plan, surgical technique, postoperative protocol, advantages and disadvantages of the new technique, pearls and pitfalls, and the more important reference for this technique. ⁷

This case is about a young man, a 25-year-old amateur-level athlete with knee pain and instability. He reported about a noncontact knee injury due to soccer trauma. He presented to our clinic 6 weeks later with crutches. Physical examination demonstrated Lachman test 3+, anterior drawer 2+, pivot shift 1+, valgus stress 2+, and range of motion (ROM) 0° extension to 125° of flexion.

In the radiograph, we can see valgus opening about 3+. In the magnetic resonance imaging (MRI) we can see the discontinuity of the anterior cruciate ligament (ACL) fibers, loosening of MCL fibers, demonstrated with the green arrows, medial meniscus injury, chondral injury grade II/ III, and bone bruise.^1,3 These were the conditions of our case. We indicate this technique for this case.

Assessment and Plan.

Diagnosis: The diagnosis included ACL tear, MCL tear, meniscus and cartilage injuries.

Operative plan: ACL reconstruction with semitendinosus triple graft by our functional technique. ⁵ MCL reconstruction with gracilis double graft by the new technique demonstrated. Meniscus and cartilage repair, if possible or if the tissue quality is sufficient.

First, we developed this new technique in the cadaver laboratory. Good results were obtained. This technique is easily reproducible.

Surgery Step 1. Examination Under Anesthesia: The ACL lesion was confirmed by a positive anterior drawer test. The Lachman test was positive, and an MCL lesion is confirmed by valgus stress. It is possible to see the opening of the medial side. The same was tested through radioscopy examination. During the movement you can see on the radioscopy the radiograph valgus stress test with opening on medial side, confirming the clinical examination.

Surgery Step 2. Tendon Harvest–Gracilis Tendon: For tendon harvest, we used an open stripper. The gracilis tendon is harvested in the usual fashion, ⁶ leaving its distal insertion pedicle fixed to the tibial bone. In this way, the preparation of the graft is performed in the double-fold surgical field, its free end is sutured with Vicryl No. 1, and the diameter of the double folded graft is measured. ⁵

Surgery Step 3. Floating Meniscus Sign: Recalling that the identification of the floating meniscus sign is one of the important criteria used to indicate the need for correction of the medial compartment, we see a typical floating meniscus on arthroscopic view. ⁴ It is possible to see in this video the movement of the meniscus. Typical floating meniscus in the MRI view; usual view of the medial compartment without adduction force for opening the medial side, and the same position with adduction force. Also shown are typical meniscocapsular injury in MRI view and typical meniscocapsular injury in arthroscopic view.

Surgery Step 4. Femoral Tunnel Position: The distal insertion of the superficial MCL is usually identified as a position 6 cm proximal to the joint line. A second longitudinal incision of the skin, approximately 2 to 3 cm over the medial epicondyle of the knee, is performed. A Steinmann pin (30 × 0.2 cm) is inserted from medial to lateral, with a slightly proximal and anterior direction, passing medially through the skin. With this set point defined, a preliminary positioning test is carried out. The graft is pulled through the skin and wrapped around the pin. The knee is put through full ROM to test graft isometry on the femoral tunnel, and the best graft position is performed.

Surgery Step 5. Femoral Tunnel Drill: A 6-mm cannulated drill is used in the previously defined femoral position, and a 2.5-cm long tunnel is made. After tunnel placement, Ethibond No. 5 sutures are used to pull the graft laterally into the tunnel in order to leave a waiting guide for the graft to make the MCL.

Surgery Step 6. Anterior Branch (Superficial MCL): The graft is then passed percutaneously under the superficial MCL, sartorius fascia, and the medial retinaculum. In this step, the knee will be positioned at 90° of flexion or in a figure-of-4 position. The graft is tensioned, pulled with the help of the guide wire, promoting the invagination of the graft within the femoral tunnel bone.

Surgery Step 7. Anterior Branch Fixation: After the graft is placed in the femoral tunnel bone, we fixed it at the same point with a soft tissue interference PEEK screw. In this position forcing a discrete varus of the knee, all the graft tips are tensioned and static.

Surgery Step 8. Posterior Branch (POL): The first part of the medial side is augmented, and at around 45° knee flexion, the free end of the remaining graft is used to augment the “functional” POL. We can see this schematic distribution on the picture. An important detail is that the second arm must come along the posterior structures of the knee. This arm will mimic the POL in a functional way without an anatomic construction.

Surgery Step 9. Posterior Branch Fixation (A Functional “POL”): This functionally contained structure, the second arm fixation, will be completely biological by suturing it to the sartorius fascia and periosteum.

Surgery Step 10. Final Test–Aesthetic incisions: The range motion is perfect, completely stable, and it is possible to see in the schematic final reconstruction view. There is no floating meniscus on the second-look arthroscopy view.

Postoperative Rehabilitation Protocol and Return to Sport: Postoperatively, we advise patients touchdown weightbearing for 2 weeks postoperatively. We don't recommend a knee brace at any time. Full weightbearing and motion is allowed at about 6 weeks, with progression of closed-chain exercises and linear-motion exercises. We typically perform formal functional testing prior to any return to sport, which is typically around 9 months postoperatively depending on the patient and the injury.

Outcome data for MCL reconstruction have demonstrated satisfactory Lysholm and Tegner scores, with most patients returning to previous activity levels. ²

Here in these tables, we demonstrate the advantages and disadvantages of the functional technique (Table 1) and the pearls and pitfalls of the functional technique (Table 2).

Finally, we demonstrate the references we use for this work. We hope that this video helps everyone. Thanks for this opportunity. These are our collaborators for this work and my address. Thank you for watching.