Anatomical Repair With Achilles Tendon Allograft Augmentation for Distal Medial Collateral Ligament Ruptures

Roberto Yáñez; Anthony Saravia; Hector Zamorano; Gaston Caracciolo; Cristobal Yañez-Rojo; Alejandro Neira; Carlos De la Fuente

doi:10.1016/j.eats.2024.103234

. 2024 Sep 21;14(3):103234. doi: 10.1016/j.eats.2024.103234

Anatomical Repair With Achilles Tendon Allograft Augmentation for Distal Medial Collateral Ligament Ruptures

Roberto Yáñez ^a, Anthony Saravia ^a, Hector Zamorano ^a, Gaston Caracciolo ^a, Cristobal Yañez-Rojo ^a, Alejandro Neira ^b, Carlos De la Fuente ^c,^∗

PMCID: PMC11977148 PMID: 40207333

Abstract

Several conditions may require medial collateral ligament (MCL) surgery, especially when high physical demands are required. Thus, we described a technique for anatomical repair of distal MCL rupture using a distal anchor and MCL augmentation through Achilles tendon allograft with proximal bone block and interference screw. This procedure fixes an anchor distally at the tibia. Then, the ligament endings are sutured using a continuous simple-type technique. Subsequently, a low-radiated Achilles tendon allograft is attached proximally and fixed through an interference screw. Finally, the allograft is sutured using a continuous simple-type technique. Our anatomical MCL repair and augmentation allows a reinforced anatomical technique to control the valgus instability caused by MCL distal ruptures, considering the MCL axial traction and posterior oblique ligament fiber orientations.

Technique Video

Download video file^{(58.4MB, mp4)}

The medial collateral ligament (MCL) restricts up to 78% of knee valgus.¹ However, injuries have a prevalence of 16.5%² and incidence of 0.24 to 7.30 per 1,000 people per year,³^,⁴ often requiring surgery.⁵ MCL deficiency increases the knee valgus, external rotation, and anteromedial internal rotation constraints.⁶ Posteromedial capsule/posterior oblique ligament (POL) deficiency can increase the internal rotation laxity during the final flexion degrees.⁶ Severe or persistent valgus instability, distal Stener-type injuries, associated anterior cruciate ligament ruptures, avulsion fractures with POL compromise, or multiligament knee injuries⁴ necessitate MCL biomechanics restoration.⁷^,⁸

MCL augmentation enhances ligamentous healing and ultimate tensile strength.9, 10, 11, 12 Furthermore, when an Achilles allograft with the bone block is used, bone-to-bone healing and a constant length (isometric reconstruction) are achieved.⁹ Although a bone block gives the Achilles allograft additional proximal attachment advantages,¹³ it is relevant to control the radiation dose to ensure that the graft strength remains unaffected.¹⁴

To perform an anatomical repair of MCL with Achilles tendon allograft augmentation, here we aim to describe the technique for anatomical repair of distal MCL rupture using a distal anchor and MCL augmentation through an Achilles tendon allograft with proximal bone block and interference screw.

Surgical Technique

Video 1 details the anatomical repair and augmentation of the MCL with an Achilles tendon. The eligibility criteria and recommendations are shown in Table 1 and Table 2, respectively.

Table 1.

Eligibility Criteria for sMCL Repair and Augmentation

Inclusion Criteria	Exclusion Criteria
• Severe valgus instability (clinical and radiologic radiograph with valgus stress) • Distal Stener-type injuries • Residual medial laxity valgus after conservative treatment grade III of MCL • Posteromedial corner injuries with POL involvement	• There is no particular restriction to using the Achilles allograft for MCL augmentation.

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MCL, medial collateral ligament; POL, posterior oblique ligament; sMCL, superficial medial collateral ligament.

Table 2.

Pearls and Pitfalls of MCL Repair and Augmentation Using an Achilles Tendon Allograft

Pearls

Pitfalls

•
This reattachment and augmentation technique is better for acute MCL injuries.
•
To confirm the MCL distal rupture through MRI images.
•
To look for the drive-through sign.
•
A standardizing technique allows for obtaining the maximum potentialities of the graft.
•
No donor site morbidity.
•
High tensile resistance of the Allograft.
•
To attach the repaired MCL 6 cm distal from the joint line to reproduce the superficial fascicle of the MCL.
•
There is a healing advantage due to anatomical fixation by bone-to-bone at the femoral insertion.
•
To insert the proximal insertion of MCL at the center of the femoral epicondyle.
•
To develop the technique with 30° of knee flexion, neutral rotation, and slight knee varus.
•
To test the valgus stress between 0° and 30° of knee flexion.

•
MCL chronic injuries make it difficult for the native MCL to reattach.
•
The intraoperative fluoroscopy should be considered to assist in the attachment of MCL.
•
The high risk of tunnel coalition at the femoral insertion should be considered when an ACL reconstruction is performed.

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ACL, anterior cruciate ligament; POL, posterior oblique ligament; MCL, medial collateral ligament; MRI, magnetic resonance imaging.

Allograft

This Technical Note follows the recommendation of Zamorano et al.¹⁴ for Achilles allograft preparations and Food and Drug Administration regulations. Blood cultures for HIV, syphilis, B and C hepatitis tests, detailed clinical records, and disease screening of donors must be added for each allograft. Allografts may receive a low dose (b2 mRad) of radiation and should be stored frozen at –80°C. Tissue cleaning and disinfecting processes should warrant no adverse mechanical or biological impairment.

Technique

Patients are placed in a supine position with the hip and knee flexed at 90°, and sedation, anesthesia, and a tourniquet are used for exploratory knee arthroscopy.¹⁵ All patients are administered antibiotic prophylaxis, according to the protocols of Zamorano et al.¹⁴

Medial knee stability, MCL, cruciate ligaments, and associated intra-articular injuries are explored by arthroscopy using conventional anteromedial and anterolateral portals between 0° and 30° of knee flexion. The drive-through sign for the medial compartment is assessed and evaluated positively when an excessive medial compartment opening (greater than 1 cm) with valgus stress at 30° of flexion is noted.¹⁶

The MCL, medial femoral condyle, interjoint line, medial tibial plateau (Fig 1A), and the open approach line crossing from the pes anserinus to medial epicondyle parallel to the posterior border of the MCL (Fig 1B and C) are marked on the skin. Then, an incision is performed from the pes anserinus toward the medial epicondyle using a No. 15 scalpel. The skin is undermined, and the sartorius fascia is dissected until the MCL is exposed using Metzenbaum curved scissors¹⁵ (Fig 1C). Special caution must be taken to avoid damaging the saphenous nerves, genicular arteries, sartorius, and pes anserinus tendons. Also, monopolar electrocauterization is used when needed. At the end of this first step, the complete visualization is permitted of the damaged superficial MLC (Fig 2A), interjoint line (Fig 2B), deep MCL, and the anterior fibers of the POL (Fig 2C).

Fig 2 — Medial knee ligaments and tibial attachment. (A) Superficial medial collateral ligament (sMCL) distal rupture. (B) Joint knee interline. (C) Anterior fibers of the posterior oblique ligament fibers (POL). (D) Tibial attachment of the sMCL. Medial view of the right leg with the patient in a supine position.

After exposure of MCL, a quadruple high-resistance No. 2 suture with equal resistance and a titanium anchor of 5.5 × 16.3 mm (AR-1928SNF-2, Corkscrew FT II Suture Anchor; Arthrex, Naples, FL) is placed at the neutral axis of the MCL 60 mm from the joint line until the distal superficial medial collateral ligament (sMCL) insertion¹⁵ (Fig 2D). The anchor tunnel is guided using an orthopaedic punch corkscrew instrument (AR-1927PB; Arthrex) as deep as the anchor mark indicates (Fig 3A). Then, the anchor tunnel is drilled through an orthopaedic punch tap corkscrew with a threaded punch to diminish the high resistance the cortical tibial bone offers to the anchor attachment (Fig 3B). This procedure prevents the anchor fracture during the surgery. The general principle of using the threaded punch is to obtain the anchor tunnel dimensions described by the fabricant. Finally, a titanium anchor of 5.5 × 16.3 mm (Corkscrew FT II Suture Anchor; Arthrex) is placed perpendicular to the tibia into the anchor tunnel (Fig 3D).

Fig 3 — Anchor attachment at distal insertion (tibial bone) of the superficial medial collateral ligament (sMCL). (A) The orthopaedic punch corkscrew is placed perpendicular to the tibia bone (yellow illustration) approximately 60 mm from the knee joint line over the sMCL traction axis drilling as depth as the fabricant recommends (white illustration). (B) The tibial tunnel is drilled through an orthopaedic threaded punch corkscrew to avoid the anchor fracture due to the high stiffness of the tibial bone. (C) Perpendicular attachment of the anchor at sMCL axis traction in the tibial bone. (D) The 4 high-resistance sutures need to repair and augment the sMCL. Medial view of the right leg with the patient in a supine position.

Once the anchor is attached, the first pair of high-resistance sutures are used to repair the sMCL and the anterior fibers of the POL. The last suture pairs are reserved for ligament augmentation. The sMCL repair begins by suturing the proximal end to the distal attachment using a terminal-terminal technique with simple continuous sutures, quadruple overhand knots, and 2 simple knots (Fig 4 A-C). Then, the POL fibers are sutured with the sMCL with simple continuous sutures and tied with a simple knot fashion⁸ (Fig 4D).

Fig 4 — Superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) suturing and knotting. (A) The distal sMCL endings are sutured and knotted. (B) A simple inverted continuous suturing technique performs across the sMCL. (C) The suturing and knotting aim a repair considering the axial traction of the sMCL. (D) The repair of sMCL also considers the suturing of POL fibers. Medial view of the right leg with the patient in a supine position.

Then, a femoral condyle tunnel at the medial epicondyle for the Achilles tendon allograft attachment is created (Fig 5A). The Achilles tendon allograft preparation typically takes 10 to 15 minutes¹⁴ and results in an allograft of 7 × 20-mm bone block (Fig 5B). The femoral tunnel is oriented through a fluoroscopy instrument, which also serves to check the final results. The condyle is drilled using a twist bit (Arthrex) to create a tunnel typically 3 to 5 mm longer than the allograft block bone,¹⁴ resulting in a femoral tunnel of 7 mm × 25 mm (Fig 5B).

Finally, the allograft is attached and guided with a Kirchner wire proximally at the medial femoral epicondyle, according to Zamorano et al.¹⁴ The tension on the repaired sMCL is given by the knee in 30° of flexion, neutral rotation, and slight varo. The bone block is fixed through a cannulated titanium interferential screw of 7 × 25 mm (AR-1371; Arthrex) with a manual screwdriver (Fig 5C). Then, the Achilles tendon allograft is continuously sutured at two-thirds distally from the middle line of the allograft, from caudal to cranial, from the repaired sMCL (inferior plane) to the allograft (superior plane) with triple central overhand knots and 2 simple knots (Fig 5D and Fig 6A). The middle portion of the posterior border of the allograft is oriented toward the POL with a simple and continuous suturing fashion (Fig 6B). The remnant allograft is dissected (Fig 6 C and D), and the medial stability is tested through a valgus stress test.¹⁷ Finally, the opened tissues are closed by a layer of absorbable VICRYL 2.0 sutures and ETHILON 3.0 sutures (Ethicon, Somerville, NJ) to close the skin.

Fig 6 — Superficial medial collateral ligament (sMCL) and anterior fibers of the posterior oblique ligament (POL) augmentation. (A) First step of sMCL augmentation. (B) Augmentation of the anterior fiber of the POL across the whole sMCL. (C) Remnant Achilles allograft. (D) Finalized augmentation of sMCL and anterior fibers of the POL. Medial view of the right leg with the patient in a supine position.

Discussion

The anisotropic nature of MCL implies an anatomical repair and reinforcement to improve the impaired MCL ultimate strength,¹²^,¹⁸ especially when the medial stability is compromised.¹⁹ Our technique proposes an anatomical repair of the MCL to restore the traction axis function of the native MCL. The technique is in coherence with anatomical repair recommendations for MCL, which has been indicated as a better repair technique than nonanatomical and tendon transfer procedures.⁸ Our technique also aims to increase the cross-sectional area of the repaired MCL and anterior fibers of the POL to obtain greater strength.⁸^,⁹^,¹¹ The choice to perform a ligament augmentation is not trivial because a typically ruptured MCL has lower mechanical properties and worse collagen conditions.¹¹^,²⁰ The pearls and pitfalls of our MCL repair and augmentation using an Achilles tendon allograft are summarized in Table 2.

Our proposed technique uses a previously standardized allograft technique.¹⁴ The anchor and bone block attachments are the rigid components. Meanwhile, sutures are the elastic and deformable components oriented both in the mechanical traction axis of the MCL and across the mechanical axis of the POL fibers, both needed for the anisometric behavior of the MCL.

In conclusion, a standardized and appropriate anatomical MCL repair and allograft augmentation allows a reinforced anatomical technique to control the valgus instability caused by MCL distal ruptures.

Disclosures

All authors (R.Y., A.S., H.Z., G.C., C.Y., A.N., C.D.F.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

C.D.F. acknowledges EEFFTO, where he is doing his voluntary (nonfunded) postdoctorate in functional and time-series statistics. The technique described in this study was developed and improved over the last 20 years by the senior knee orthopaedic surgeon R.Y. A.S. thanks the MEDS clinic, where he did an orthopedic fellowship. Furthermore, he thanks the orthopaedic seniors C. Sandoval, M.D., C. Azar, M.D., and F. Vergara, M.D., for their support during their orthopaedic fellowship. A.N. thanks the Universidad Mayor (Santiago, Chile) for funding the article processing charges of this publication through UM publication grant.

Supplementary Data

Video 1

After the arthroscopy examination, the anatomical landmarks on the skin are marked, and a longitudinal skin incision is made to expose the superficial medial collateral ligament. The open approach line crosses from the pes anserinus to the medial epicondyle parallel to the posterior border of the superficial medial collateral ligament. The superficial knee and sartorius fascia are dissected until exposure to the distal rupture. Then, complete visualization of the damaged superficial medial collateral ligament, inter-joint line, deep medial collateral ligament, and the anterior fibers of the posterior oblique ligament is permitted. The anchor tunnel is guided using an orthopaedic punch corkscrew instrument located 6 cm distally from the knee interline. Then, the anchor tunnel is drilled through an orthopaedic punch tap corkscrew with a threaded punch to diminish the high resistance that the cortical tibial bone offers to the anchor attachment. This procedure prevents the anchor fracture during the surgery. Finally, a titanium anchor is placed perpendicular to the tibia. Once the anchor is attached, the first pair of high-resistance sutures are used to repair the superficial medial collateral ligament and the anterior fibers of the posterior oblique ligament. The superficial medial collateral ligament is repaired by suturing the proximal end to the distal attachment. Terminal-terminal suture techniques with simple continuous sutures, quadruple overhand knots, and two simple knots are used during the ligament repair. The posterior oblique ligament fibers are sutured with the superficial medial collateral ligament with simple continuous sutures and tied with a simple knot. The Achilles allograft is attached and guided by a Kirchner wire proximally at the medial femoral epicondyle, according to Zamorano et al. The bone block is fixed through a cannulated titanium interferential screw through a manual screwdriver. The last suture pairs are reserved for ligament augmentation. Thus, the tendon allograft is continuously sutured at two-thirds distally from the middle line of the allograft, from caudal to cranial, from the repaired superficial medial collateral ligament (inferior plane) to the allograft (superior plane) with triple central overhand knots and 2 simple knots. The middle portion of the posterior border of the allograft is oriented toward the posterior oblique ligament in a simple and continuous suturing fashion. The remnant allograft is dissected, and the medial stability is tested using a valgus stress test. See pearls and pitfalls in Table 2.

Download video file^{(58.4MB, mp4)}

References

1.Phisitkul P., James S.L., Wolf B.R., Amendola A. MCL injuries of the knee: Current concepts review. Iowa Orthop J. 2006;26:77–90. [PMC free article] [PubMed] [Google Scholar]
2.Cristiani R., van de Bunt F., Kvist J., Stålman A. High prevalence of superficial and deep medial collateral ligament injuries on magnetic resonance imaging in patients with anterior cruciate ligament tears. Arthroscopy. 2024;40:103–110. doi: 10.1016/j.arthro.2023.05.029. [DOI] [PubMed] [Google Scholar]
3.Vosoughi F., Rezaei Dogahe R., Nuri A., Ayati Firoozabadi M., Mortazavi J. Medial collateral ligament injury of the knee: A review on current concept and management. Arch Bone Jt Surg. 2021;9:255–262. doi: 10.22038/abjs.2021.48458.2401. [DOI] [PMC free article] [PubMed] [Google Scholar]
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8.DeLong J.M., Waterman B.R. surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: A systematic review. Arthroscopy. 2015;31:2258–2272.e1. doi: 10.1016/j.arthro.2015.05.011. [DOI] [PubMed] [Google Scholar]
9.Marx R.G., Hetsroni I. Surgical technique: Medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470:798–805. doi: 10.1007/s11999-011-1941-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Mowers C., Jackson G.R., Condon J.J., et al. Medial collateral ligament reconstruction and repair show similar improvement in outcome scores, but repair shows higher rates of knee stiffness and failure: A systematic review. Arthroscopy. 2023;39:2231–2240. doi: 10.1016/j.arthro.2023.03.002. [DOI] [PubMed] [Google Scholar]
11.Kubo T., Takahashi T., Saitsu A., Ae R., Sekiya H., Takeshita K. Material properties of suture augmentation of knee medial collateral ligament repair did not influence length changes or failure loads in a caged porcine model. Arthrosc Sports Med Rehabil. 2023;5:e629–e635. doi: 10.1016/j.asmr.2023.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Holuba K., Vermeijden H.D., Yang X.A., O’Brien R., van der List J.P., DiFelice G.S. Treating combined anterior cruciate ligament and medial collateral ligament injuries operatively in the acute setting is potentially advantageous. Arthroscopy. 2023;39:1099–1107. doi: 10.1016/j.arthro.2022.06.023. [DOI] [PubMed] [Google Scholar]
13.Kang S.H., Sohn K.M., Lee D.K., Lee B.H., Yang S.W., Wang J.H. Arthroscopic posterior cruciate ligament reconstruction: The Achilles tendon allograft versus the quadriceps tendon allograft. J Knee Surg. 2020;33:553–559. doi: 10.1055/s-0039-1681029. [DOI] [PubMed] [Google Scholar]
14.Zamorano H., Yáñez-Diaz R., Vergara F., et al. Achilles tendon allograft preparation technique for anterior cruciate ligament reconstruction: A technical note. Arthrosc Tech. 2021;10:e2143–e2150. doi: 10.1016/j.eats.2021.05.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Trofa D.P., Sonnenfeld J.J., Song D.J., Lynch T.S. Distal knee medial collateral ligament repair with suture augmentation. Arthrosc Tech. 2018;7:e921–e926. doi: 10.1016/j.eats.2018.05.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Billières J., Hopper G.P., Carrozzo A., et al. Arthroscopic medial compartment drive-through sign for knee medial collateral ligament complex injuries. Arthrosc Tech. 2022;11:e763–e766. doi: 10.1016/j.eats.2021.12.034. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Jung K.H., Youm Y.S., Cho S.D., Jin W.Y., Kwon S.H. Iatrogenic medial collateral ligament injury by valgus stress during arthroscopic surgery of the knee. Arthroscopy. 2019;35:1520–1524. doi: 10.1016/j.arthro.2018.11.054. [DOI] [PubMed] [Google Scholar]
18.Willinger L., Shinohara S., Athwal K.K., Ball S., Williams A., Amis A.A. Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc. 2020;28:3720–3732. doi: 10.1007/s00167-020-06050-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Ren D., Liu Y., Zhang X., Song Z., Lu J., Wang P. The evaluation of the role of medial collateral ligament maintaining knee stability by a finite element analysis. J Orthop Surg Res. 2017;12:64. doi: 10.1186/s13018-017-0566-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Encinas-Ullán C.A., Rodríguez-Merchán E.C. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev. 2018;3:398–407. doi: 10.1302/2058-5241.3.170035. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Download video file^{(58.4MB, mp4)}

Video 1

Download video file^{(58.4MB, mp4)}

[bib1] 1.Phisitkul P., James S.L., Wolf B.R., Amendola A. MCL injuries of the knee: Current concepts review. Iowa Orthop J. 2006;26:77–90. [PMC free article] [PubMed] [Google Scholar]

[bib2] 2.Cristiani R., van de Bunt F., Kvist J., Stålman A. High prevalence of superficial and deep medial collateral ligament injuries on magnetic resonance imaging in patients with anterior cruciate ligament tears. Arthroscopy. 2024;40:103–110. doi: 10.1016/j.arthro.2023.05.029. [DOI] [PubMed] [Google Scholar]

[bib3] 3.Vosoughi F., Rezaei Dogahe R., Nuri A., Ayati Firoozabadi M., Mortazavi J. Medial collateral ligament injury of the knee: A review on current concept and management. Arch Bone Jt Surg. 2021;9:255–262. doi: 10.22038/abjs.2021.48458.2401. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib4] 4.Kim C., Chasse P.M., Taylor D.C. Return to play after medial collateral ligament injury. Clin Sports Med. 2016;35:679–696. doi: 10.1016/j.csm.2016.05.011. [DOI] [PubMed] [Google Scholar]

[bib5] 5.Lavoie-Gagne O.Z., Retzky J., Diaz C.C., et al. Return-to-play times and player performance after medial collateral ligament injury in elite-level European soccer players. Orthop J Sports Med. 2021;9 doi: 10.1177/23259671211033904. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib6] 6.Miyaji N., Holthof S.R., Ball S.V., Williams A., Amis A.A. Medial collateral ligament reconstruction for anteromedial instability of the knee: A biomechanical study in vitro. Am J Sports Med. 2022;50:1823–1831. doi: 10.1177/03635465221092118. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib7] 7.LaPrade M.D., Kennedy M.I., Wijdicks C.A., LaPrade R.F. Anatomy and biomechanics of the medial side of the knee and their surgical implications. Sports Med Arthrosc Rev. 2015;23:63–70. doi: 10.1097/JSA.0000000000000054. [DOI] [PubMed] [Google Scholar]

[bib8] 8.DeLong J.M., Waterman B.R. surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: A systematic review. Arthroscopy. 2015;31:2258–2272.e1. doi: 10.1016/j.arthro.2015.05.011. [DOI] [PubMed] [Google Scholar]

[bib9] 9.Marx R.G., Hetsroni I. Surgical technique: Medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470:798–805. doi: 10.1007/s11999-011-1941-8. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib10] 10.Mowers C., Jackson G.R., Condon J.J., et al. Medial collateral ligament reconstruction and repair show similar improvement in outcome scores, but repair shows higher rates of knee stiffness and failure: A systematic review. Arthroscopy. 2023;39:2231–2240. doi: 10.1016/j.arthro.2023.03.002. [DOI] [PubMed] [Google Scholar]

[bib11] 11.Kubo T., Takahashi T., Saitsu A., Ae R., Sekiya H., Takeshita K. Material properties of suture augmentation of knee medial collateral ligament repair did not influence length changes or failure loads in a caged porcine model. Arthrosc Sports Med Rehabil. 2023;5:e629–e635. doi: 10.1016/j.asmr.2023.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib12] 12.Holuba K., Vermeijden H.D., Yang X.A., O’Brien R., van der List J.P., DiFelice G.S. Treating combined anterior cruciate ligament and medial collateral ligament injuries operatively in the acute setting is potentially advantageous. Arthroscopy. 2023;39:1099–1107. doi: 10.1016/j.arthro.2022.06.023. [DOI] [PubMed] [Google Scholar]

[bib13] 13.Kang S.H., Sohn K.M., Lee D.K., Lee B.H., Yang S.W., Wang J.H. Arthroscopic posterior cruciate ligament reconstruction: The Achilles tendon allograft versus the quadriceps tendon allograft. J Knee Surg. 2020;33:553–559. doi: 10.1055/s-0039-1681029. [DOI] [PubMed] [Google Scholar]

[bib14] 14.Zamorano H., Yáñez-Diaz R., Vergara F., et al. Achilles tendon allograft preparation technique for anterior cruciate ligament reconstruction: A technical note. Arthrosc Tech. 2021;10:e2143–e2150. doi: 10.1016/j.eats.2021.05.016. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib15] 15.Trofa D.P., Sonnenfeld J.J., Song D.J., Lynch T.S. Distal knee medial collateral ligament repair with suture augmentation. Arthrosc Tech. 2018;7:e921–e926. doi: 10.1016/j.eats.2018.05.001. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib16] 16.Billières J., Hopper G.P., Carrozzo A., et al. Arthroscopic medial compartment drive-through sign for knee medial collateral ligament complex injuries. Arthrosc Tech. 2022;11:e763–e766. doi: 10.1016/j.eats.2021.12.034. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib17] 17.Jung K.H., Youm Y.S., Cho S.D., Jin W.Y., Kwon S.H. Iatrogenic medial collateral ligament injury by valgus stress during arthroscopic surgery of the knee. Arthroscopy. 2019;35:1520–1524. doi: 10.1016/j.arthro.2018.11.054. [DOI] [PubMed] [Google Scholar]

[bib18] 18.Willinger L., Shinohara S., Athwal K.K., Ball S., Williams A., Amis A.A. Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc. 2020;28:3720–3732. doi: 10.1007/s00167-020-06050-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib19] 19.Ren D., Liu Y., Zhang X., Song Z., Lu J., Wang P. The evaluation of the role of medial collateral ligament maintaining knee stability by a finite element analysis. J Orthop Surg Res. 2017;12:64. doi: 10.1186/s13018-017-0566-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib20] 20.Encinas-Ullán C.A., Rodríguez-Merchán E.C. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev. 2018;3:398–407. doi: 10.1302/2058-5241.3.170035. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Anatomical Repair With Achilles Tendon Allograft Augmentation for Distal Medial Collateral Ligament Ruptures

Roberto Yáñez, Ph.D., M.D.

Anthony Saravia, M.D.

Hector Zamorano, M.D.

Gaston Caracciolo, M.D.

Cristobal Yañez-Rojo, M.D.

Alejandro Neira, M.Sc.

Carlos De la Fuente, Ph.D.

Abstract

Technique Video