Medial Collateral Ligament Reconstruction With Anteromedial Reinforcement for Medial and Anteromedial Rotatory Instability of the Knee

Abstract

Even though structures of the medial side of the knee have a high potential to heal without surgery, in some circumstances injuries of this region may lead to development of chronic medial and anteromedial rotatory instability (AMRI). In those circumstances, surgery should be performed. Current-day surgical techniques are focused on recreating the function of the main stabilizers of the medial side of the knee, which are the medial collateral ligament and the posterior oblique ligament, but they omit the role of the anteromedial capsule. Nonetheless, they are able to restore at most "near-native" biomechanics of the joint, are highly invasive, and require advanced skills in posteromedial knee surgery. Maybe we should take a look at chronic medial instability and AMRI from the other side? We present a minimally invasive reconstruction of the superficial medial collateral ligament with anteromedial reinforcement for the AMRI component. Level of evidence: 1 (knee) and 2 (collateral ligaments).

© 2019 by the Arthroscopy Association of North America. Published by Elsevier.

Figures

Fig 1

Medial side of the right knee. Semitendinosus tendon (ST-T) harvested from its proximal part, using an open-ended hamstring stripper, with preserved tibial attachment. Medial portals after previously performed arthroscopy are visible.

Fig 2

Medial side of the right knee in flexion. A natural path under intact gracilis tendon (G-T) and sartorius (Sar) is found along the course of the superficial medial collateral ligament to the medial epicondyle (ME) using a long, sequentially closed and opened Pean's forceps (white arrow). ST-T, semitendinosus tendon.

Fig 3

Medial side of the right knee in flexion. The second 4-cm-long incision at the level of the medial epicondyle is performed just above the tip (white arrow with green contour) of Pean's forceps (white arrow with orange contour) introduced through the natural path of the superficial medial collateral ligament below the lower margin of gracilis tendon (G-T) and sartorius (Sar).

Fig 4

(A) Medial side of the right knee in flexion. The medial epicondyle (ME) is identified by palpation. A 1.6-mm Kirschner wire (K-wire) (white arrow) is placed in the point 3.2 mm proximal and 4.8 mm posterior to the center of the ME as the starting point for the isometry assessment. (B) Medial side of the right knee. Semitendinosus tendon (ST-T) graft is wrapped around the K-wire (white arrow), placed in the potential femoral point of isometry, and marked with a sterile marker (blue arrow). The isometry of the graft is checked through the full range of knee motion and confirmed when the mark on the graft does not move >1 mm from the K-wire. G-T, gracilis tendon; Sar, sartorius.

Fig 5

Medial side of the right knee. Semitendinosus tendon (ST-T) graft is double-folded at the ToggleLoc device with ZipLoop Technology and whipstitched at a distance of 2 cm with MaxBraid Suture No. 2. A Kirschner wire is placed in the femoral point of isometry (white arrow).

Fig 6

Medial side of the right knee in flexion. The drill (white arrow) matched to the size of the double-folded semitendinosus tendon (ST-T) graft is used to make a femoral tunnel for stabilization of the whipstitched part. The drill should be directed proximally and anteriorly.

Fig 7

Medial side of the right knee in flexion. (A) The whipstitched part of the semitendinosus tendon (ST-T) graft (white arrow) is introduced to the femoral tunnel, fixed on the lateral cortex with a ToggleLoc device, and properly tensioned with tensioning sutures (MaxBraid Suture No. 5) (black arrow). A blunt elevator (blue arrow) is used to facilitate introducing the graft. (B) The whipstitched part of the ST-T graft is introduced to the femoral tunnel and tensioned with MaxBraid Suture No. 5 (white arrow), forming an anterior branch, which performs anteromedial reinforcement. The free part of the semitendinosus tendon graft (fST-T) will be used for superficial medial collateral ligament reconstruction.

Fig 8

Medial side of the right knee in flexion. Proximal tibia. The Kirschner wire (white arrow) is positioned in the potential point of isometry on the line parallel and close to the posterior tibial cortex. The isometry is checked in the previously described manner. G-T, gracilis tendon; Sar, sartorius, sMCL, native superficial medial collateral ligament; ST-T, semitendinosus tendon graft.

Fig 9

Medial side of the right knee in flexion. Proximal tibia. The drill (white arrow) is used to create the tibial tunnel for superficial medial collateral ligament (sMCL) reconstruction in the point of isometry. ST-T, semitendinosus tendon graft.

Fig 10

Medial side of the right knee in flexion. Proximal tibia. The whipstitched semitendinosus tendon (ST-T) graft and tensioning strands of the ToggleLoc device (white arrow) are sequentially introduced to the tibial tunnel. G-T, gracilis tendon; Sar, sartorius; sMCL, native medial collateral ligament.

Fig 11

(A) Medial side of the proximal tibia. The whipstitched semitendinosus tendon (ST-T) graft stabilized with the Guardsman Interference Screw (white arrow). (B) Lateral side of the proximal tibia. Secondary stabilization on the lateral tibial cortex with the cortical button. G-T, gracilis tendon; Sar, sartorius; sMCL, native medial collateral ligament.