On-lay Anatomical Reconstruction of the Superficial and Deep MCL and POL With Hamstrings Tendons Autograft

Abstract

Background:

Injuries to the medial collateral ligament (MCL) and the posterior oblique ligament (POL), isolated or associated with cruciate ligament tear, are common in cases of knee sprains and often cause valgus instability. Although there are many surgical techniques for MCL reconstruction, not all are anatomical, and not all involve reconstruction of the deep and superficial bundles of the MCL and POL with an autologous autograft.

Indications:

We propose this technique in cases of chronic anterior cruciate ligament (ACL) tear associated with POL and MCL injury grade III according to the Hughston-Eilers classification.

Technique Description:

This technique involves an on-lay anatomical reconstruction of the superficial and deep bundles of the MCL and POL using hamstring tendons. The patient is in a supine position with the knee flexed at 90°. An incision is made in the medial compartment of the knee, at the level of the medial collateral ligament, after which the hamstring tendons are harvested with an open tendon stripper so that they can be left inserted at their tibial insertion. Three soft tissue self-punching anchors are positioned at the anatomical insertion of the MCL and POL bundles. Care must be taken not to involve the joint surface, which is easily visible through a needle. The tendons are secured using the previously positioned anchors to reconstruct the MCL and POL.

Results:

After 5 months, the patient returned to her daily activities, fully recovered knee range of motion, and achieved good recovery of muscle strength without discomfort or functional limitations.

Discussion/Conclusion:

This technique provides an anatomical reconstruction of the MCL and POL using on-lay all suture anchors for chronic lesions. Hastring autografts are used for MCL and POL reconstruction, leaving other autografts available for ACL reconstruction. There is no need for an additional tunnel for MCL and POL reconstruction, thus avoiding tunnel convergence in multiligament reconstructions.

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.

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DOI: 10.1177/26350254261421937.M1

Video Transcript

This video journal discusses the on-lay anatomical reconstruction of the superficial and deep medial collateral ligament and the posterior oblique ligament using hamstring tendon autograft.

Background

Injuries to the medial collateral ligament (MCL) and the posterior oblique ligament (POL) are common after a knee sprain caused by valgus stress and tibial external rotation. These injuries typically occur alone but are often associated with other knee ligament injuries, particularly an anterior cruciate ligament (ACL) injury.^1,2,10

In general, the MCL has a high intrinsic healing capacity; grade I and II injuries are usually treated conservatively ² ; the treatment of grade III injuries is a matter of debate between conservative and surgical treatment. ⁸

For acute injuries, the recommended surgical treatment is repair, ⁷ while for chronic injuries, reconstruction is recommended. There are many surgical techniques for reconstruction using autografts or allografts. However, anatomical reconstructions of MCL and POL using autografts are not commonly performed today. ³

Indications

In this case, we have a 25-year-old female amateur soccer player who had a motorcycle accident and sprained her right knee. She was initially treated conservatively at another hospital. Four months after the trauma, she came to our hospital complaining of knee instability and functional limitations. During the visit, the knee was swollen with full range of motion, although painful at maximum flexion. The Lachman test was positive (+), and the Valgus stress test was markedly positive (+++) at 0° and 30° of flexion.

She underwent magnetic resonance imaging and radiographs of her knee, and a valgus stress test was performed. The lesion was classified as grade III using the Hughston-Eilers classification system. ⁴

The indication was to perform an ACL, MCL, and POL reconstruction.

Technique Description

Patient is in the supine position. Physical examination under general anesthesia revealed complex knee instability. The Lachman test was positive (+), and the valgus stress test was markedly positive (+++) at 0° and 30° of flexion, and the anterior drawer in external rotation was 3+. The stress radiograph with fluoroscope confirmed a grade III MCL tear. After performing ACL reconstruction with a quad tendon autograft, a 10 to 12-cm incision is made from the proximal insertion of the MCL to the pes anserinus. The semitendinosus and gracilis tendons are identified, harvested with an open-ended tendon stripper, and then prepared by leaving them attached to their distal insertion. The joint space is identified using a needle. The soft tissue self-punching anchors are being positioned: 1 at the tibial insertion of the deep MCL, 1 at the femoral insertion of the superficial MCL, and the last one approximately 1.5 cm posterior to the anchor positioned at the tibial insertion of the deep MCL, at the insertion site of the POL. The gracilis tendon is fixed at the tibial insertion site of the POL, with the knee in neutral position and at 30° of flexion; then, it is fixed, always with the knee in neutral position and at 30° of flexion, at the level of the femoral epicondyle with the semitendinosus tendon to reconstruct the POL and the superficial layer of the MCL, respectively. The remaining portion of the semitendinosus is then fixed back distally with the anchor at the tibial insertion of the deep MCL, with the knee at 30° of flexion and in neutral position. Finally, it is passed through a tibial tunnel at the anatomical insertion site of the superficial MCL and fixed with an interference screw (IS), with the knee always at 30° of flexion and in neutral position (Figure 1).

Figure 1.

Graphic representation of the MCL and POL reconstruction technique. The circles at the A, B, and C levels represent soft-tissue self-punching anchors. The star represents the tibial insertion of the hamstring tendons. The dotted line shows the course of the semitendinosus tendon, and the continuous line shows the course of the gracilis tendon. A-B: POL; B-C: Deep MCL; C-D: Superficial MCL. The interference screw is placed at the D level. MCL, medial collateral ligament; POL, posterior oblique ligament.

Results

Starting on the first day after surgery, continuous passive motion using the Kinetec was performed for 30 days, progressively achieving knee flexion. The quadriceps femoris muscle, especially the vastus medialis obliquus, was immediately activated.

After 4 weeks, manual physio kinesitherapy was started to restore knee range of motion and muscle strength.

For the first 3 weeks, weightbearing was not allowed, and it was necessary to wear the knee brace flexed at 20°. For the following 3 weeks, weightbearing was still not allowed, but the brace was locked in extension. For the following 2 weeks, full weightbearing was allowed, but the brace was always worn locked in extension. For the last 4 weeks, the brace was removed, but walking was allowed only with 2 crutches. At the end of the 4 weeks, the crutches were also removed.

Discussion/Conclusion

Numerous techniques have been studied over the years to reconstruct the medial complex of the knee, but not all of them are able to restore the true anatomy of the medial compartment of the knee.

Xu et al ⁹ published a technique for anatomical reconstruction of the MCL and POL using an allograft; they reported good results, although with some complications.

In 2019, Lee et al ⁵ studied an anatomical technique for reconstructing the MCL and POL, but in this case, too, an allograft was used, and only the superficial bundle of the MCL was reconstructed.

Unlike the latter techniques, Madonna et al ⁶ proposed a technique that uses the autologous semitendinosus tendon. The semitendinosus is used for reconstruction of the POL and the superficial bundle of the MCL. However, unlike our technique, this technique does not consider reconstruction of the deep bundle of the MCL.

This technique allows for the anatomical reconstruction of the MCL and POL using hamstring tendons that remain attached to their tibial insertions, providing greater stability to the graft and good clinical outcomes.