The medial collateral ligament (MCL) consists of the deep and superficial components, with the latter providing the primary restraint to a valgus force.1,2 In isolation, acute MCL injuries can be treated nonoperatively with good outcomes.3,4 However, a surgeon may be more inclined to address an MCL deficiency in certain scenarios, such as a multiligamentous injury to provide additional stability to the knee.
At the authors' institution, the senior author (E.H.A.) commonly performs an MCL reconstruction when treating multiligamentous knee injuries. To the best of the authors' knowledge, the MCL reconstruction technique used by the senior author has not been previously described in the literature. This suspensory fixation-based construct incorporates a semitendinosus autograft that preserves the native insertion on the pes anserinus and is passed through femoral and tibial bone tunnels.
The patient is positioned supine on the operating room table. An anteromedial incision is made, exposing the femoral and tibial insertions of the MCL. While the pes anserine insertion is carefully preserved, the semitendinosus tendon is identified and harvested in a retrograde fashion using an open tendon stripper (Figure 1). The semitendinosus is still attached to the pes anserinus with the proximal end of the graft now free (Figure 2).
Semitendinosus is harvested using an open stripper.
The proximal aspect of the semitendinosus is free while the pes anserine insertion remains intact.
Given that the authors usually perform MCL reconstruction in cases with concomitant multiligament injuries, an arthroscopy is then performed to diagnose and address any other intra-articular findings. Subsequently, torn cruciate ligaments are reconstructed. The MCL reconstruction is performed as the final stage in a multiligamentous knee injury.
The semitendinosus autograft is doubled over a Tightrope (Arthrex, Naples, Florida) and sized (Figures 3–4). A Fibertape (Arthrex) is also passed through the Tightrope loop to serve as an internal brace. At the femoral origin of the MCL, a spade-tipped drill reamer is used to drill bicortically. This tunnel is then overdrilled with an appropriately sized reamer (a size 7 in this case) to match the width of the doubled autograft (Figure 5). The Tightrope, internal brace, and graft are inserted into the femoral tunnel, and the button is flipped on the lateral cortex of the femur (Figure 6). This is confirmed fluoroscopically. Approximately 2 cm of graft is pulled into the femoral tunnel at this time, given that the Tightrope will be tensioned as the final step of the reconstruction.
The autograft is looped over a Tightrope (Arthrex, Naples, Florida).
The doubled graft is sized.
At the medial collateral ligament origin, the femoral tunnel is drilled bicortically and overreamed unicortically to match the width of the graft.
The Tightrope (Arthrex, Naples, Florida) and graft construct are passed into the femoral tunnel.
The free end of the semitendinosus autograft is then prepared with Fiberloop (Arthrex) suture, attached to a distal biceps button, and measured for width (Figure 7). The tibial insertion site of the MCL is identified by finding the point of isometry. The tibial tunnel is drilled at the site of the MCL insertion, with caution taken to avoid the previously drilled tunnels for the cruciate ligament reconstructions. The distal biceps button with the free end of the semitendinosus graft, along with the 2 ends of the internal brace Fibertape, is passed into the tibial tunnel (Figure 8). The Fibertape internal brace is shuttled to the lateral aspect of the tibia, which will be tensioned separately in the upcoming steps. The button attached to the graft is flipped on the lateral tibial cortex. With the use of the tension slide technique, the graft is pulled into the tibia (Figure 9). With the graft preliminary secured in the tibial tunnel, the semitendinosus is tensioned at 30° of knee flexion, placed in varus, and maximally tensioned through the Tightrope in the femoral tunnel. Once appropriate tension has been placed on the graft, the ends of the Fibertape internal brace are longitudinally pulled, and an interference screw is placed in the tibial tunnel, thus independently tensioning the internal brace construct (Figure 10). The authors feel that the interference screw, in addition to the biceps button, provides further stability against tibial fixation failure, as well as separate tensioning of the graft and internal brace constructs. Final tensioning is once again applied through the femoral-sided Tightrope, yielding the completed MCL construct (Figures 11–12). The knee is tested for stability in varus and valgus intraoperatively before final closure occurs.
The free end of the graft is prepared and measured.
The distal biceps button is attached to the tibial side of the autograft.
With the use of the tension slide technique, the distal biceps button and the free end of the autograft are passed into the tibial tunnel.
An interference screw is placed into the tibial tunnel.
Final medial collateral ligament construct.
Anteroposterior (A) and lateral (B) radiographs of a patient who underwent a medial collateral ligament reconstruction in addition to anterior cruciate ligament and posterior cruciate ligament reconstructions.
Postoperatively, the patient is placed in a hinged knee brace. In general, weight bearing is delayed for 6 weeks, and range of motion begins immediately.
A recent review by DeLong and Waterman5 found 28 MCL reconstruction techniques. Numerous methods were described, including single and double bundle, anatomic and nonanatomic, autograft and allograft, various graft fixation devices (screw, cortical button, staple), and an assortment of approaches to graft tensioning. It is difficult to assess the superiority of 1 specific method given the heterogeneity of the surgical techniques, variety of outcome measures, differing concomitant knee injuries, limited long-term results, and small patient populations.
The authors believe that their MCL reconstruction technique offers several distinct advantages. This technique offers a balance of isometry and strength and minimized potential for soft tissue irritation. Because there is 1 small tibial tunnel, the point of isometry is easily and reproducibly identified. This point of MCL isometry can be identified on the tibial attachment through various techniques. Often, this location is at the level of the pes anserinus, so the single small tunnel is anatomically possible to create.
The authors also believe that the strength of this construct is optimized through both the proximal Tightrope fixation and the distal button fixation with interference screw backup. As the hamstring tendon is maintained at its tibial insertion, only 1 site of healing is needed—the proximal hamstring tendon in the tibial tunnel. This is in contrast to more historical methods that require femoral and tibial fixation sites. Additionally, historical methods relying on aperture-based fixation have the potential for soft tissue irritation, specifically of the pes anserinus. Anecdotally, if positioned correctly, staple fixation, used for Achilles allograft MCL reconstruction, reliably leads to medial soft tissue irritation and clinical pain. Finally, surgical healing is reinforced with internal brace fixation. This additional strength allows for more accelerated rehabilitation protocols as the graft matures and the soft tissue heals.
However, there are several limitations to this technique. The MCL bone tunnels must be drilled around those of the cruciate ligaments in a multiligament reconstruction. This has the potential for tunnel convergence. Harvesting an autograft will create additional graft site morbidity to a multiply injured knee. Although the authors feel that their patients have done well with this reconstruction method based on clinical examination and subjective findings, they do not have long-term, objective functional scores to compare with other techniques that have been described.
The authors have reported an MCL reconstruction technique that, to the best of their knowledge, has not been previously described. It provides several advantages, including reproducible isometric graft placement, optimized fixation strength, and internal bracing.
- Griffith CJ, LaPrade RF, Johansen S, Armitage B, Wijdicks C, Engebretsen L. Medial knee injury: Part 1. Static function of the individual components of the main medial knee structures. Am J Sports Med. 2009; 37(9):1762–1770. doi:10.1177/0363546509333852 [CrossRef]
- Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010; 92(5):1266–1280. doi:10.2106/JBJS.I.01229 [CrossRef]
- Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983; 65(3):323–329. doi:10.2106/00004623-198365030-00005 [CrossRef]
- Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Relat Res. 1990; 256:174–177.
- DeLong JM, Waterman BR. Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: a systematic review. Arthroscopy. 2015; 31(11):2258–2272. doi:10.1016/j.arthro.2015.05.011 [CrossRef]