Minimally-Invasive,Retensionable,Onlay Double-Bundle Medial Collateral Ligament Reconstruction

Abstract

Background:

The superficial medial collateral ligament (sMCL) is the most injured knee ligament, and the most commonly coinjured ligament in anterior cruciate ligament tears. The technique's goal is to be less invasive while maintaining the hamstrings’ function.

Indications:

Surgical indications for this technique include isolated grade 3 injuries that fail nonoperative management and multiligament knee injuries that include the MCL.

Technique Description:

Items needed for the double-bundle reconstruction technique include an anterior tibialis graft > 270 mm, C-Arm for visualization of radiographic landmarks, 2 knotless all-suture anchors, and an adjustable-loop suspensory fixation device. First, create a 3-4–cm incision over the distal tibial insertion of the sMCL, approximately 6 cm from the joint line. Then, split the hamstring fascia and identify the distal tibial insertion of the sMCL. Create a bleeding bed of bone at the anterior and posterior aspects of the distal tibial insertion of the sMCL. Place a knotless suture anchor at the anterior aspect of the distal tibial insertion of the sMCL and a knotless suture anchor at the posterior aspect of the distal tibial insertion of the sMCL. Proximally, identify LaPrade's radiographic femoral landmark for the origin of the sMCL. Make a 1-cm incision over this radiographic landmark. Then, place a spade-tip guide pin through the radiographic landmark, the femur, and the lateral cortex. This creates a femoral reconstruction socket. Then, shuttle the allograft into position from distal to proximal. Pull it into the femoral socket with the loop suspensory device. Then, secure it distally with 2 knotless suture anchors. Final tension is performed with the suspensory loop device with the assistance of arthroscopic viewing of the medial compartment.

Results:

This technique has been performed clinically by the senior author for the past 7 years. No reoperations nor revision surgeries have been required in the senior author's practice.

Discussion/Conclusion:

This minimally-invasive, retensionable, onlay double-bundle MCL reconstruction technique effectively restores medial knee stability and does not compromise the hamstrings' function to provide medial dynamic knee stability.

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

Background

This is a minimally-invasive, on-lay, double-bundle medial collateral ligament (MCL) reconstruction. MCL reconstruction is a necessity, as it is the most commonly injured ligament. The most commonly coinjured ligament is the anterior cruciate ligament. ¹ Isolated grade 3 injuries that fail nonoperative management are our surgical indications, as are multiligament knee injury patterns.

The hamstrings are a dynamic medial stabilizer of the knee, whereas in some reconstructions, they are used as an autograft and have long incisions. We have adopted a more minimally-invasive technique that uses an allograft. The goal of the technique is to be less invasive and not compromise the hamstrings’ function.

It mirrors a 2-incision medial patellofemoral ligament (MPFL) reconstruction, and we have been using it successfully for the past 7 years. Our case presentation involves a 36-year-old professional pilot. He fell off a pull-up bar 4 months previously.

Indications

He was using a hinged knee brace, but he had been unable to return to running and basketball. However, he has been able to continue as a commercial pilot. On physical examination, he had a grade 3 opening at 30° and a grade 1 at 0°. His mechanical axis was neutral, and magnetic resonance imaging evaluation revealed remote proximal MCL injury. In these cases, you can use stress ultrasound to guide you. LaPrade has described the opening you will see on the contralateral side, with just an isolated grade 3 superficial MCL at 3.2 mm, and on the other side, a complete injury near 10 mm.

Stress radiographs can help you ensure that surgical intervention is indicated. Also, make sure you have a long enough allograft. We typically use an anterior tibialis >270 mm.

Also, review the radiographic landmarks described by LaPrade and his group. ² You can also print it out as a job aid for your case.

Technique Description

We use a C-arm for these cases and perform the procedure with the patient in the supine position. Recently, in our laboratory, we conducted an anatomical study that looked at the positioning of the C-arm. If you shoot the x-ray from medial to lateral, it facilitates it, and it is more consistent. For the procedure overview, we make an incision at the distal tibial insertion, 6 cm from the joint line. We split the hamstring fascia and identify this distal insertion. We then identify Laprade's radiographic landmark proximally and make a small stab incision at this location, large enough for your fingers, so you can do some dissection just to clear the soft tissues. ²

We place a guide pin under fluoroscopic guidance, which is a lot like finding the Shottle point for MPFL reconstructions, so if you use that for MPFL reconstructions, you are comfortable with and familiar with it. Then, after we get our guide pin, we recreate our reconstruction socket, shuttle this allograft underneath the hamstring fascia and into position, secure it distally with 2 knotless anchors, and advance it proximally into the socket. Then, you can tension and retension and view intra-articularly to guide your tensioning. We clinically started this in 2018 and previously created a technique video for one of our industry partners.

We have also biomechanically validated it and are submitting for publication in 2026. Under anesthesia, you can see his opening is apparent. So, I am lengthening the tight rope. The length of the tightrope (Arthrex, Inc) that I want to create is about the width of the femur. So, I can pull it in, flip the button, and still have access outside of the body. Our graft length needs to be >270 mm to be sufficient, and we whipstitched each end of the graft. Midway from the back to the front of the tibia, you can feel the pez, which is right where the superficial MCL inserts, and LaPrade describes this at 6 cm from the joint line, right? So, it is about 6 cm; feel the pez here.

With that pez, I am going to split that fascia, and then run it this way. So, I sped up this video, and I will talk over it from here. Here, I have split the hamstrings, and if you take it distally, you can just use a 15-blade or a key elevator to lift off the hamstrings distally and those metz to open the fascia. Then an Army-Navy works nicely for the anterior exposure, and then either another Army-Navy or a Homan retractor on the back of the tibia works nicely as well. So, that is the superficial MCL's distal insertion. We create a nice bleeding bed of bone.

Here, I am using a small meniscal rasp, but I usually use a larger rasp. That is what we had in this case. We are going to put in the 2 knotless FiberTaks (Arthrex, Inc), the ones that we typically use for these. They have 2 preconverted loops you can use to secure your graft.

In our laboratory, we have explored different methods for securing tendon grafts with these anchors, and I will show you my current technique. You will have a blue loop and a black loop.

We inserted those anchors. Now, we are going to find that proximal insertion utilizing image intensification. Radiographic landmarks described by LaPrade and colleagues are used to find the superficial MCL footprint. I am going to make an incision about 1 cm and use my finger to dissect the soft tissues. We are going to place a guide pin, which is just like MPFL reconstruction: which often uses Shottle's radiographic point for MPFL purposes. However, we use Laprade's radiographic landmark for the proximal MCL to place our guide pin for this MCL reconstruction. Then, we are going to shuttle our graft into position.

To shuttle it, we first make sure it is sized up. It is typically about 9 mm in diameter, the size of our socket in the femur. I dilate with a tonsil, pass a shuttle suture into position, shuttle our graft into position, and then secure it distally.

That just kind of gets it to where I want and holds it provisionally in place. Now, shuttle it up into position. For our distal fixation, we typically send the graft through the blue, then send the black up through the graft and around it. So, you will see the graft go through the blue loop simply. Now, I am going to take a free needle and send this Vicryl (Ethicon, Inc), which is attached to the black loop through the graft, pull the loop through the graft, fold it back on itself, tension the black down, and then tension the blue down. Now, they are also going to take it and turn it up at the end, and send the limbs through and tie them as well.

We are creating our 9-mm socket into position. This socket can be too short; it cannot be too long, unless you go through the far cortex. Then, we will shuttle our button across. This is an important step just to be deliberate. If you go through the iliotibial (IT) band, it is not the end of the world, but it takes a little bit of time to dissect it all.

So, now that we have our button flipped, we are going to advance our graft into our socket.

After we have our graft in the socket, we will complete the distal fixation. We have tensioned provisionally, but we always want the option to eliminate more slack if necessary.

I am going to put the knee at about 30°, and just a gentle varus force, and then do our final tension. As we view intra-articularly, the previous gapping is gone. The nice thing about this technique is that you can tension and retension it as well as view intra-articularly to guide your final tension.

The last thing we will do is fold the graft up, pass the black through the graft, and pass the blue through the graft—just the limbs of the knotless mechanism—then tie the black to the blue over the top.

Also, it just compresses the graft down nicely to the bone even further.

I am showing you on one limb, and we, of course, do the same for the second limb. Then, you will see me tying the black and the blue together. After we tied the black and the blue together, we trimmed the tissue, and the last step is to close the fascia over the top.

We close the fascial layer with Vicryl and then the skin. That is finished.

Results and Discussion

Clinical Pearls

Split the hamstring fascia as distally as possible, and maybe even raise a small portion of the hamstrings off. It will not hurt anything; it just helps with visualization.

Go slow when pressing your Tightrope button to ensure you do not pull it through the IT band. Use the C-arm to guide the button passage and view arthroscopically to confirm that you are happy with your joint stability. You can also cycle the knee, and then retension your device, which really does help restore more of the native state according to our biomechanical validation study.

Potential Complications

There is always a risk of reinjury and arthrofibrosis, which I have not run into clinically, but we do worry about that with MCL reconstructions and saphenous nerve irritation.

My Immediate Postoperative Protocol

For range of motion restrictions, I put them in a hinged knee brace, lock them while our post-operative nerve block is in place, then unlock them once our block is out. Patients are toe-touch weightbearing for 4 weeks, followed by a 2-week crutch weaning protocol.

We begin strengthening at 6 weeks, jogging at 12 weeks, and agility at 16 weeks. Return to sports is 4 to 6 months, depending on the individual's timeline. We retrospectively reviewed our use of this technique for 2 years and found 13 patients. On chart review, no reinjuries or reoperations were reported.

For further research, we have already compared this to validated constructs and are looking to have that presented and published in 2026.