Abstract
The medial collateral ligament serves as the primary stabilizer to valgus stress on the medial side of the knee and is the most commonly injured ligament in the knee. Medial collateral ligament reconstruction can provide improved stability and clinical outcomes for patients. Advancements in techniques, including the use of an adjustable-length-loop suspensory fixation device through a longitudinal incision, have been introduced in recent years. The purpose of this Technical Note and video is to provide a minimally invasive method for medial collateral ligament reconstruction with adjustable-loop femoral fixation and posteromedial corner plication.
Technique Video
Medial collateral ligament (MCL) reconstruction of the knee with Achilles tendon allograft using adjustable-loop cortical suspensory fixation on the femoral side is performed on a cadaveric specimen. An Achilles tendon allograft of approximately 15 cm has been prepared for this technique, reflecting the typical distance between the femoral and tibial attachments of the superficial MCL. We begin by identifying the radiographic marker for the femoral insertion, at the point of intersection between Blumensaat line and the posterior cortex. A 2.5-cm incision is made over this point and soft-tissue dissection is performed down to the medial distal femoral cortex. A guidepin is placed directly on bone and inserted with fluoroscopic guidance. Next, a similar process is performed distally at the tibial insertion, approximately 6 to 7 cm below the joint line. A soft-tissue sleeve of the pes tendons and sartorius expansion is created for later closure. A washer is used to guide pin placement, with the washer being placed as posteriorly as possible without exceeding the posterior margin of the tibia. Suture tape is pulled through the sartorius expansion and looped around both guidepins. The knee is cycled through flexion and extension to ensure isometry. On the tibial side, a 3.2-mm drill bit is advanced bicortically for later graft fixation with a 4.5-mm screw. On the femoral side, a reamer is used to create a tunnel of 40 to 50 mm in depth, and a spade tip is used to confirm femoral osseous length, after which it is pushed through the skin on the lateral leg to allow passage of suspensory sutures. The TightRope suture and graft are marked to identify appropriate placement and advanced in the femoral tunnel until the button engages. Provisional tensioning is performed, followed by placement of the tibial end of the graft through the sartorius expansio. A bicortical screw and washer are inserted through a longitudinal incision in the distal graft over the tibial attachment site and locking whip stitches are placed just proximal to this site. The tails of the locking whip stitches are pulled deep to the washer and tensioned during final tightening. The sutures are then tied to create a suture post-washer post construct, and excess graft is excised. The proximal construct suture is then retensioned with the knee at 30° of flexion and maximum varus, and an interference screw is placed using a nitinol wire, establishing double fixation. Although not shown in the video, 2 suture anchors are then placed 12 mm distal to the joint line into the proximal tibia, recreating the proximal tibial MCL insertion. Soft-tissue closure is performed in usual layered fashion, with the pes tendon–sartorius expansion soft-tissue sleeve closed in a single layer.
The medial collateral ligament (MCL) is the largest structure on the medial aspect of the knee, running from its attachment point 3.2 mm proximal and 4.8 mm posterior to the medial femoral epicondyle to its tibial insertions into soft tissue and within the pes anserine bursa.1 It serves as the primary stabilizer on the medial side of the knee, acting as the main restraint to valgus stress, external rotation forces at 30° of flexion, and internal rotation at all degrees of flexion, as well as contributing to stability against anterior translation forces on the tibia.2
The MCL is also the most commonly injured ligament in the knee, primarily occurring in young, athletic individuals, and is often concomitantly injured with anterior cruciate ligament tears.3 The majority of MCL injuries are amenable to nonoperative management and rehabilitation; however, there are multiple indications for operative management of MCL injuries, including open injury, knee dislocation with associated multiligament knee injury, and persistent symptoms of pain and instability despite conservative treatment.2,4,5 Specifically, reconstruction may be appropriate in cases of chronic injury, failed repair, or poor ligament quality,2 and previous investigation has demonstrated acceptable ligamentous stability and improved clinical outcomes after MCL reconstruction.5, 6, 7
Historically, a variety of MCL-reconstruction techniques have been used with various types of grafts and fixation methods across different patient populations, although none has shown clear superiority.8 In recent years, significant advancements have been made in reconstruction techniques including the implementation of an adjustable length-loop suspensory fixation through a medial longitudinal incision, published by Deo and Getgood9 in 2015, which provides the opportunity to tension and retension, allowing for fine-tuning of graft tension to the desired level. When surgical intervention is indicated, our preferred technique is a minimally invasive MCL reconstruction using an Achilles tendon allograft and adjustable-loop femoral fixation along with posteromedial corner plication (Table 1 and Video 1).
Table 1.
Indications and Contraindications of MCL Reconstruction
| Indications |
| Multiligament knee injury |
| Injury to associated structures (ie, deep MCL, semimembranosus) |
| Chronic valgus instability |
| Contraindications |
| Isolated MCL injury amenable to conservative management |
| Acute repairable injury |
MCL, medial collateral ligament.
Surgical Technique (With Video Illustration)
Video 1 shows a minimally invasive medial collateral ligament reconstruction using an Achilles tendon allograft and adjustable-loop femoral fixation along with posteromedial corner plication is shown. The patient is positioned supine with the operative leg secured in an arthroscopic leg holder. The C-arm is positioned contralateral to the operative side of the patient, and fluoroscopy is used to mark the femoral incision site and to locate the femoral insertion point of the MCL.
Patient Preparation
The patient is placed in a supine position with the surgical limb secured in an arthroscopic leg holder and the contralateral leg in a foam well-leg holder. After the induction of general anesthesia, an examination with the patient under anesthesia is performed to assess knee stability and range of motion, including varus and valgus stress at 0° and 30° flexion, Lachman, reverse Lachman, posterior drawer, dial test at 30° and 90° flexion. Intraoperative stress view radiographs may be obtained before prepping and draping.
Graft Preparation
An Achilles tendon allograft of approximately 15 cm is soaked in vancomycin and platelet-rich plasma. The graft is prepared in usual fashion with a FiberTag TightRope (Arthrex, Naples, FL) on what is to be the femoral side and a locking stitch on the tibial side (Fig 1). The graft is passed through a graft sizing block to determine the appropriate tunnel size for reconstruction.
Fig 1.
The Achilles allograft is prepared to a length of 15 cm. (A) The TightRope is attached in standard fashion on what is to be the femoral side of the graft, and a single locking stitch is placed on the tibial side. (B) The cortical button with adjustable fixation is shown.
Surgical Approach: Femoral Insertion
The femoral insertion of the MCL approximately 2.5 cm proximal to the joint line is identified on fluoroscopy with a guidepin at the point where Blumensaat line and posterior cortex intersect (Fig 2A). This area is marked with a marking pen and repeat radiographs are performed to confirm placement before making a 2.5-cm incision. Soft-tissue dissection is continued through the fascia down to the medial distal femoral cortex. A guidepin is placed directly onto the bone through the incision at the anatomic insertion site of the superficial MCL and again verified to be in appropriate position on fluoroscopy (Fig 2B). Finally, the pin is inserted. Surrounding soft tissues are cleared.
Fig 2.
Lateral radiograph of a cadaveric lower extremity. (A) Initial placement of a guidepin over the intersection of the posterior cortex and Blumensaat line approximate the native femoral insertion of the sMCL. An incision is made, and soft-tissue dissection is continued down to the level of the bone. (B) Repeat fluoroscopy is performed to confirm appropriate guide pin placement. Views are lateral fluoroscopic views of right knee. (sMCL, superficial medial collateral ligament.)
Surgical Approach: Tibial Insertion
The skin is marked 6 to 7 cm below the joint line and a 30-cm longitudinal incision is made distally. Soft-tissue dissection is carried down to the sartorius expansion. A soft-tissue sleeve consisting of the pes tendons and sartorius expansion is elevated posteriorly and the distal MCL fibers can be seen. The center of the distal MCL insertion is identified and marked in the video with Metzenbaum scissors, but this would typically be done with the Bovie (Fig 3A). A washer is used to guide pin placement with the washer placed as posteriorly as possible without exceeding the posterior margin of the tibia (Fig 3B).
Fig 3.
The tibial insertion of the sMCL is found 6 to 7 cm distal to the joint line. After dissecting the pes tendon and revealing the sartorius expansion, the distal fibers of the sMCL are identified. (A) A mark is made over the center of the sMCL fibers. (B) A washer is used to guide placement of the tibial guide pin, with the washer placed as posteriorly as possible without exceeding the posterior margin of the tibia. View is of medial aspect of right knee. (sMCL, superficial medial collateral ligament.)
Isometric Confirmation
A needle driver is inserted distal-to-proximal under the sartorius expansion and suture tape is pulled through, looping around both guide pins. With the knee in full extension and the distal end of the suture tape under tension, the suture tape is marked with a marking pen on the femoral side. The knee is then cycled through flexion and extension, ensuring that the marked area does not move (Fig 4), confirming isometry.
Fig 4.
Suture tape is fed through the sartorius expansion in a proximal-to-distal fashion, looping around both the femoral and tibial guide pins. The proximal suture tape is marked while tension is maintained distally at the tibial guide pin. The knee is then cycled through (A) extension and (B) flexion to ensure isometry and no movement of the marked end. View is of medial aspect of right knee.
Tunnel Creation
The tibial pin is removed, and a 3.2-mm drill bit is advanced bicortically to accept future 4.5-mm screw (Arthrex) for graft fixation. Next, returning to the femoral insertion, a reamer is used to create a tunnel 40 to 50 mm in depth. This length of socket is crucial to ensure there is adequate socket depth for retensioning of the graft after being secured distally. The guide pin is exchanged for a spade tip to confirm femoral osseous length on fluoroscopy, then pushed through the skin on the lateral aspect of the leg to allow passage of the suspensory sutures out through the medial side (Fig 5).
Fig 5.
(A) After reaming the femoral cortex, the guide pin is exchanged for a spade tip. (B) The cortical depth of the femoral tunnel is measured with the spade tip and confirmed via fluoroscopy. (C) The spade tip is then pushed through the lateral aspect of the leg, through the skin, to allow for passage of the adjustable-loop fixation. View is of medial aspect of right knee (A and C) and anteroposterior fluoroscopy of right knee (B).
Graft Placement
The TightRope on the graft is marked at the femoral osseous length (75 mm) from where the button will flip. The graft itself is marked at approximately 20 mm from the femoral side, denoting the ideal depth of graft within the femoral tunnel. Next, the TightRope and button are advanced until the button engages against the cortex of the medial distal femur and provisionally tensioned. The distal end of the graft is then pulled through the trough under the sartorius expansion to the distal attachment site. The graft is incised longitudinally adjacent to the tibial insertion. Locking whip stitches are placed just proximal to the window. A bicortical screw and washer are then inserted through the window and provisionally tightened to secure the graft distally. The tails of the locking whip stitches are pulled deep to the washer and used to pull distally during final tightening of the distal screw and spiked washer. Finally, the sutures are tied underneath the excess graft to create a suture post-washer post construct (Fig 6), and the excess graft is excised.
Fig 6.
(A) The TightRope is passed through the femoral tunnel, with preliminary tensioning done to partially insert the graft. (B) The graft is then passed through the sartorius expansion to the distal end. (C) An incision is made over the center of the tendon overlying the tibial insertion, and (D) multiple whip stitches are placed just proximal to this incision. (E) Initial placement of the screw and washer is performed. (F) The suture tails of the whip stitches are tied below and posterior to the screw and washer. The screw is then fully tightened and excess graft is excised, finalizing creation of a suture postwasher postconstruct on the tibial side. View is antero-posterior view of right knee (A) and medial aspect of right knee (B-F).
Retensioning the Femoral End
Returning to the proximal construct, the suture is retensioned with the knee at 30° of flexion and maximum varus, ensuring 20 mm of graft pulled into the femoral tunnel. A nitinol wire is placed in the femoral socket adjacent to the graft to guide the placement of a BioComposite FastThread Interference Screw (Arthrex), creating double fixation on the femoral side.
Proximal Tibial Graft Fixation
Two FASTak Suture Anchors (Arthrex) are placed into the proximal tibia, 12 mm distal to the joint line. The sutures are passed through the graft in mattress fashion to recreate the proximal tibial MCL insertion (Fig 7).
Fig 7.
Intraoperative fluoroscopic image following MCL reconstruction using adjustable-loop femoral fixation. A suture anchor is placed at the end of the procedure approximately 12 mm distal to the joint line, approximating the proximal sMCL insertion site. View demonstrates anteroposterior fluoroscopy of left knee. (sMCL, superficial medial collateral ligament.)
Soft-Tissue Closure
Tissue over the femoral construct is copiously irrigated and closed in usual layered fashion. On the tibial side, after irrigation, the sartorius expansion is first closed along with the pes tendons in a single large sleeve, and the remainder of the surgical site is closed in usual fashion.
Discussion
This Technical Note is a modification of an open anatomic MCL-reconstruction technique previously published from this institution and the preceding Marx technique on which it was based.10,11 The present technique is similar in approach and graft placement to the Marx and Prince techniques but implements the use of an adjustable loop for femoral fixation. Adjustable-loop femoral fixation has been previously described by Deo et al. in 2015; however, this technique used hamstring autograft and an open approach, whereas the present Technical Note uses a minimally invasive approach, Achilles allograft, and additional proximal tibial fixation with 2 anchors9 (Table 2).
Table 2.
Technique Pearls and Pitfalls of MCL Reconstruction with Adjustable Loop Fixation
| Pearls |
| Use fluoroscopy to mark the femoral incision, which is frequently more posterior than anticipated Confirm femoral and tibial fixation isometry before drilling tunnels Provisionally dock the first 20 mm of graft into the femoral tunnel, then fix on tibial side, allowing for femoral retensioning Retension graft in 30° of knee flexion and maximum varus |
| Pitfalls |
| Proceeding with tunnel creation before confirmation of isometry may lead to an anisometric graft and suboptimal stability through range of motion Finalizing fixation on the femoral side with an interference screw before tibial fixation will circumvent the ability to retension the graft Graft tensioning in positions other than 30° of flexion and varus may lead to over/underconstraint |
MCL, medial collateral ligament.
The advantages of the present technique include the minimally invasive approach requiring only 2 small incisions, robust and modifiable femoral fixation with the FiberTag TightRope, and broad tendon coverage at the tibia closely reflecting that of the native MCL insertion. The disadvantages of this technique are the need for an allograft and possible hardware irritation due to the screw and washer fixation on the tibia (Table 3).
Table 3.
Advantages and Disadvantages of MCL Reconstruction
| Advantages |
| Minimally invasive approach requiring 2 small incisions |
| Robust and modifiable femoral fixation with adjustable loop |
| Broad tendon coverage at tibia, similar to native MCL |
| Disadvantages |
| Need for allograft |
| Possible hardware irritation |
MCL, medial collateral ligament.
Disclosure
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Supported by the Foderaro-Quattrone Musculoskeletal-Orthopaedic Surgery Research Innovation Fund. This study was partially funded partially by the following: National Institute of Arthritis and Musculoskeletal and Skin Diseases for the Musculoskeletal Research Training Program (T32AR56950). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. M.H. reports personal fees from DJO Enovis, Moximed, and Vericel; publishing royalties from Elsevier; and editorial board of Journal of Cartilage and Joint Preservation. B.A.L. reports royalties and consulting fees from Arthrex; stock or stock Options from COVR Medical LLC; consulting fees from Smith & Nephew; and editorial or governing board of Journal of Knee Surgery, Knee Surgery, Sports Traumatology, Arthroscopy, and Orthopedics Today. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Footnotes
Primary location where this investigation was performed: Mayo Clinic, Rochester, Minnesota, U.S.A.
Supplementary Data
Medial collateral ligament (MCL) reconstruction of the knee with Achilles tendon allograft using adjustable-loop cortical suspensory fixation on the femoral side is performed on a cadaveric specimen. An Achilles tendon allograft of approximately 15 cm has been prepared for this technique, reflecting the typical distance between the femoral and tibial attachments of the superficial MCL. We begin by identifying the radiographic marker for the femoral insertion, at the point of intersection between Blumensaat line and the posterior cortex. A 2.5-cm incision is made over this point and soft-tissue dissection is performed down to the medial distal femoral cortex. A guidepin is placed directly on bone and inserted with fluoroscopic guidance. Next, a similar process is performed distally at the tibial insertion, approximately 6 to 7 cm below the joint line. A soft-tissue sleeve of the pes tendons and sartorius expansion is created for later closure. A washer is used to guide pin placement, with the washer being placed as posteriorly as possible without exceeding the posterior margin of the tibia. Suture tape is pulled through the sartorius expansion and looped around both guidepins. The knee is cycled through flexion and extension to ensure isometry. On the tibial side, a 3.2-mm drill bit is advanced bicortically for later graft fixation with a 4.5-mm screw. On the femoral side, a reamer is used to create a tunnel of 40 to 50 mm in depth, and a spade tip is used to confirm femoral osseous length, after which it is pushed through the skin on the lateral leg to allow passage of suspensory sutures. The TightRope suture and graft are marked to identify appropriate placement and advanced in the femoral tunnel until the button engages. Provisional tensioning is performed, followed by placement of the tibial end of the graft through the sartorius expansio. A bicortical screw and washer are inserted through a longitudinal incision in the distal graft over the tibial attachment site and locking whip stitches are placed just proximal to this site. The tails of the locking whip stitches are pulled deep to the washer and tensioned during final tightening. The sutures are then tied to create a suture post-washer post construct, and excess graft is excised. The proximal construct suture is then retensioned with the knee at 30° of flexion and maximum varus, and an interference screw is placed using a nitinol wire, establishing double fixation. Although not shown in the video, 2 suture anchors are then placed 12 mm distal to the joint line into the proximal tibia, recreating the proximal tibial MCL insertion. Soft-tissue closure is performed in usual layered fashion, with the pes tendon–sartorius expansion soft-tissue sleeve closed in a single layer.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Medial collateral ligament (MCL) reconstruction of the knee with Achilles tendon allograft using adjustable-loop cortical suspensory fixation on the femoral side is performed on a cadaveric specimen. An Achilles tendon allograft of approximately 15 cm has been prepared for this technique, reflecting the typical distance between the femoral and tibial attachments of the superficial MCL. We begin by identifying the radiographic marker for the femoral insertion, at the point of intersection between Blumensaat line and the posterior cortex. A 2.5-cm incision is made over this point and soft-tissue dissection is performed down to the medial distal femoral cortex. A guidepin is placed directly on bone and inserted with fluoroscopic guidance. Next, a similar process is performed distally at the tibial insertion, approximately 6 to 7 cm below the joint line. A soft-tissue sleeve of the pes tendons and sartorius expansion is created for later closure. A washer is used to guide pin placement, with the washer being placed as posteriorly as possible without exceeding the posterior margin of the tibia. Suture tape is pulled through the sartorius expansion and looped around both guidepins. The knee is cycled through flexion and extension to ensure isometry. On the tibial side, a 3.2-mm drill bit is advanced bicortically for later graft fixation with a 4.5-mm screw. On the femoral side, a reamer is used to create a tunnel of 40 to 50 mm in depth, and a spade tip is used to confirm femoral osseous length, after which it is pushed through the skin on the lateral leg to allow passage of suspensory sutures. The TightRope suture and graft are marked to identify appropriate placement and advanced in the femoral tunnel until the button engages. Provisional tensioning is performed, followed by placement of the tibial end of the graft through the sartorius expansio. A bicortical screw and washer are inserted through a longitudinal incision in the distal graft over the tibial attachment site and locking whip stitches are placed just proximal to this site. The tails of the locking whip stitches are pulled deep to the washer and tensioned during final tightening. The sutures are then tied to create a suture post-washer post construct, and excess graft is excised. The proximal construct suture is then retensioned with the knee at 30° of flexion and maximum varus, and an interference screw is placed using a nitinol wire, establishing double fixation. Although not shown in the video, 2 suture anchors are then placed 12 mm distal to the joint line into the proximal tibia, recreating the proximal tibial MCL insertion. Soft-tissue closure is performed in usual layered fashion, with the pes tendon–sartorius expansion soft-tissue sleeve closed in a single layer.
Medial collateral ligament (MCL) reconstruction of the knee with Achilles tendon allograft using adjustable-loop cortical suspensory fixation on the femoral side is performed on a cadaveric specimen. An Achilles tendon allograft of approximately 15 cm has been prepared for this technique, reflecting the typical distance between the femoral and tibial attachments of the superficial MCL. We begin by identifying the radiographic marker for the femoral insertion, at the point of intersection between Blumensaat line and the posterior cortex. A 2.5-cm incision is made over this point and soft-tissue dissection is performed down to the medial distal femoral cortex. A guidepin is placed directly on bone and inserted with fluoroscopic guidance. Next, a similar process is performed distally at the tibial insertion, approximately 6 to 7 cm below the joint line. A soft-tissue sleeve of the pes tendons and sartorius expansion is created for later closure. A washer is used to guide pin placement, with the washer being placed as posteriorly as possible without exceeding the posterior margin of the tibia. Suture tape is pulled through the sartorius expansion and looped around both guidepins. The knee is cycled through flexion and extension to ensure isometry. On the tibial side, a 3.2-mm drill bit is advanced bicortically for later graft fixation with a 4.5-mm screw. On the femoral side, a reamer is used to create a tunnel of 40 to 50 mm in depth, and a spade tip is used to confirm femoral osseous length, after which it is pushed through the skin on the lateral leg to allow passage of suspensory sutures. The TightRope suture and graft are marked to identify appropriate placement and advanced in the femoral tunnel until the button engages. Provisional tensioning is performed, followed by placement of the tibial end of the graft through the sartorius expansio. A bicortical screw and washer are inserted through a longitudinal incision in the distal graft over the tibial attachment site and locking whip stitches are placed just proximal to this site. The tails of the locking whip stitches are pulled deep to the washer and tensioned during final tightening. The sutures are then tied to create a suture post-washer post construct, and excess graft is excised. The proximal construct suture is then retensioned with the knee at 30° of flexion and maximum varus, and an interference screw is placed using a nitinol wire, establishing double fixation. Although not shown in the video, 2 suture anchors are then placed 12 mm distal to the joint line into the proximal tibia, recreating the proximal tibial MCL insertion. Soft-tissue closure is performed in usual layered fashion, with the pes tendon–sartorius expansion soft-tissue sleeve closed in a single layer.