curso de instrucción: alrededor del pivote central ... · warren rf, marshall jl. the supporting...

CursodeInstrucción:AlrededordelPivoteCentral

LigamentoColateralMedialPresidente:JuanBlanco

DiegoGarcía-Germán

WarrenRF,MarshallJL.The supporting structures andlayers on the medialsideofthe knee:an anatomical analysis.JBone Joint Surg Am1979;61(1):56–62

as coursing distal-proximal, from the adductor tubercle tothe medial patella. The MPFL femoral attachment hasreported to be located 1.9mm anterior and 3.8mm distal tothe adductor tubercle, where the femoral attachments of thesMCL and the AMT are also located (Fig. 4).2 From thisfemoral attachment the tendon is said to “fan out,” and forma wider attachment to the medial patella, likewise it is saidthat a gradual thickening occurs in the ligament from thepatella to its femoral attachment.20,21 The MPFL also hasfibers that merge into the deep aspect of the vastus medialisobliquus.2 The association between merging MPFL fibersinto the vastus medialis obliquus infers the relationship ofthese 2 structures in preserving a transverse orientation,which helps maintain patellar stability.20

Pes Anserinus (Gracilis, Sartorius, andSemitendinosus) Tendons

The pes anserinus, or hamstring tendons, attach at theanteromedial aspect of the proximal part of the tibia.2 Thepes anserinus tendons, which form the roof of the pesanserine bursa, are most commonly described in the fol-lowing order from proximal to distal: sartorius, gracilis,and semitendinosus (Fig. 5).2,23,24 Grassi et al23 reportedthat the gracilis and semitendinosus were covered by a thinfibrotic cap formed by the sartorius tendon, which makesaccess to the gracilis and semitendinosus more restrictedthan the sartorius. The gracilis and semitendinosus tendons

are most commonly used as autografts for kneereconstructions.23,25

Medial MeniscusThe medial meniscus is a C-shaped fibrocartilaginous

bumper and shock absorber that is situated between themedial femoral condyle and medial tibial plateau.26,27 Onaverage, the medial meniscus is approximately 40.5 to45.5mm long and 27mm wide; however, the sizes can differsignificantly depending on the height, weight, and sex of thepatient.26,27 There are 2 main attachment sites of the medialmeniscus, the anteromedial and posteromedial roots.28

MGTThe tendon attachment of the MGT is located in a

depression over the posteromedial edge of the medialfemoral condyle, just proximal and posterior to a thirdosseous prominence (gastrocnemius tubercle) (Fig. 2A).2

LaPrade et al2 found that the average proximal and pos-terior distances to the gastrocnemius tubercle were 2.6 and3.1mm, respectively. The MGT has 2 other fascial attach-ments, thick and thin, along its lateral aspect to the AMT,and along its posterior-medial aspect to the capsular arm ofthe POL.2 The combination of foot plantar flexion andknee extension has been shown by Patterson et al29 to causeeccentric contraction of the MGT, which results in stressingof the medial head of the gastrocnemius at its femoralorigin.

FIGURE 2. A, Illustration of the main structures of the medial knee. B, Photograph of the ligamentous attachments to the medialfemoral epicondyle (MFE) by the superficial medial collateral ligament (sMCL), posterior oblique ligament (POL), medial gastrocnemiustendon (MGT), and adductor magnus tendon (AMT) (medial view, left knee). AMT indicates adductor magnus tendon; MGT, medialgastrocnemius tubercle; MPFL, medial patellofemoral ligament; SM, semimembranosus muscle; sMCL, superficial medial collateralligament; POL, posterior oblique ligament; VMO, vastus medialis obliquus muscle. Reproduced with permission from LaPrade et al.2

Sports Med Arthrosc Rev ! Volume 23, Number 2, June 2015 Anatomy and Biomechanics of the Medial Knee

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LaPradeMD,KennedyMI,Wijdicks CA,LaPradeRF.Anatomy andBiomechanics ofthe MedialSide oftheKnee andTheir Surgical Implications.Sports Med Arthrosc Rev 2015;23:63–70

reconstruction, but our reconstruction was only validated

using 7-mm reconstruction grafts [3]. After the recon-struction tunnel was prepared, we then turned our attention

to identification of the posterior oblique ligament tibial

reconstruction tunnel. The attachment site of the centralarm of the posterior oblique ligament was identified at the

posteromedial tibia, just slightly anterior to the direct arm

attachment of the semimembranosus tendon. Exposure ofthis attachment site was performed through a small inci-

sion parallel to the fibers of the posterior edge of the

anterior arm of the semimembranosus tendon. Once thiswas identified, an eyelet passing pin was similarly drilled

across the tibia toward Gerdy’s tubercle. Once it was

verified this eyelet pin was in the correct anatomic loca-tion, a 7-mm reamer drilled the tunnel to a depth

of 25 mm.

The attachment locations of the superficial medial col-lateral ligament and posterior oblique ligament on the

femur were next identified (Fig. 3). In some circumstances,

intraoperative fluoroscopy may be required to assist withidentification of the correct femoral attachments sites [14].

To best identify these landmarks, we recommend isolation

of the distal attachment of the adductor magnus tendoninitially. The bony prominence slightly distal to its

attachment is the adductor tubercle. One can then identify

the medial epicondyle by visualizing the bony prominencedistal to this and almost parallel to the shaft of the femur.

On average, the medial epicondyle is 12.6 mm distal and

8.3 mm anterior to the adductor tubercle. The attachmentsite of the superficial medial collateral ligament is slightly

proximal and anterior to this location. Once this site wasidentified, an eyelet passing pin was drilled transversely

across the femur. It is not recommended to ream this tunnel

until the attachment site of the posterior oblique ligamenthas been definitively identified.

The next surgical step was to identify the posterior

oblique ligament femoral attachment. If the entire postero-medial capsule was torn off the femur, we identified the

medial gastrocnemius tendon, followed it to its femoral

attachment site, and then identified the gastrocnemiustubercle by its adjacent nature to this attachment site. On

average, the gastrocnemius tubercle is 2.6 mm distal and

3.1 mm anterior to the medial gastrocnemius tendon fem-oral attachment. The posterior oblique ligament femoral

attachment is 7.7 mm distal and 2.9 mm anterior to the

gastrocnemius tubercle. If the posteromedial capsule wasstill intact, a small incision posterior to the remnants of the

superficial medial collateral ligament, vertical and into the

joint, was placed to identify the femoral attachment site ofthe central arm of the posterior oblique ligament. An eyelet

passing pin was then similarly drilled across the femur.

Once this was done, a 7-mm reamer drilled each recon-struction tunnel to a depth of 25 mm. It is recommended to

not separately ream these tunnels before verification of theattachment sites of both structures because of the potential

of having a tunnel not located in the ideal location.

We found the reconstruction grafts for the superficialmedial collateral ligament should be 16 cm in length,

whereas those for the posterior oblique ligament should

be 12 cm in length. Although these reconstruction graftlengths may need to be changed in very small or much

larger patients, we have found they have fit the require-

ments both for our in vivo and in vitro reconstructions andconsistently allowed for a minimum of 25 mm of graft to

be placed within the reconstruction tunnels.

The superficial medial collateral ligament and posterioroblique ligament grafts were then pulled into their

Fig. 2 A photograph of a left knee demonstrates the course of thesuperficial medial collateral ligament (arrows).

Fig. 3 A photograph of a right knee demonstrates the relationshipsbetween the femoral attachments of the superficial medial collateralligament (scissors deep to superficial medial collateral ligament), theposterior oblique ligament, and the adductor magnus tendon (inforceps). SM = semimembranosus; MGT = medial gastrocnemiustendon.

808 LaPrade and Wijdicks Clinical Orthopaedics and Related Research1

123

LaPradeRF,Wijdicks CA.The ManagementofInjuriesto the MedialSide ofthe Knee.JOrthop Sports Phys Ther 2012;42(3):221-233

Anatomía

• LCMs• LCMp• POL• Otras:

–GemeloInterno–Semimembranoso–Aductormayor

Anatomía

• LCMs–Fémur:

• 3mmproximaly5mmposterioralepicóndilo medial

–Tibia:• Prox:(Partesblandas)12mmdistalalaarticulación

• Distal:6cmdistalalaarticulación,margenposteriordetibia

journal of orthopaedic & sports physical therapy | volume 42 | number 3 | march 2012 | 225

valgus stress test performed with the knee at full extension should demonstrate only 1 to 2 mm of increased medial compart-ment gapping compared to the contralat-eral side; more gapping would indicate a combined cruciate ligament injury.7 Increased valgus gapping in extension is usually an indication of a more severe combined medial knee and cruciate liga-ment injury. Assessment of the amount of medial compartment gapping at 20° of knee flexion predominantly isolates the superficial MCL, with the roles of the cru-ciate ligaments, deep MCL, and posterior oblique ligament being less important. Feeling for an end point during this test is important to differentiate between a partial and complete medial knee injury.7

Assessment of the amount of antero-

medial rotation in a medial knee injury is also important to determine whether the injury primarily affects the superfi-cial MCL or the posterior oblique liga-ment and deep MCL. The anteromedial drawer test is performed with the knee flexed approximately 80° to 90° and the foot externally rotated 10° to 15°. A cou-pled anterior and external rotatory force is applied to the knee, and the amount of anteromedial tibial rotation is assessed. It is important to visually assess the amount of anteromedial tibial rotation, rather than posterolateral tibial rotation, because the amount of external tibial ro-tation that occurs is very similar to that demonstrated during a positive postero-lateral drawer test.

The dial test should be performed at

both 30° and 90° of knee flexion to evalu-ate suspected medial knee injuries (FIG-URE 8).7,9 In the past, a positive dial test was reported to be pathognomonic of a posterolateral corner injury, but biome-chanical testing has demonstrated that a positive dial test can also be present at both 30° and 90° of knee flexion in an isolated medial knee injury.7 Thus it is important to examine these patients both in the supine and prone positions when performing the dial test to deter-mine whether the amount of external rotation is due to anteromedial or pos-terolateral tibial rotation. When the dial test is performed in the prone position, it can more accurately allow for objective visualization of the amount of increased side-to-side external rotation; however, palpation and visualization of actual tib-ial subluxation must be performed in the supine position.

Radiographic DiagnosisValgus stress radiographs are very useful to objectively identify a medial knee in-jury. These radiographs are usually per-formed at 20° of knee flexion with a foam bolster under the knee, and a comparison is made between the amounts of medial compartment gapping in the injured and uninjured contralateral knee (FIGURE 9). It has been reported that a grade III injury to the superficial MCL results in 3.2 mm of increased medial compartment gapping at 20° of knee flexion.13 Complete sectioning of the superficial MCL, posterior oblique ligament, and deep MCL resulted in 9.8 mm of increased medial compartment gapping at 20° of knee flexion.13 Thus, valgus stress radiographs can be a valu-able adjunct to the clinical examination by quantifying the amount of medial com-partment gapping in a medial knee injury and, when the diagnosis is in doubt, deter-mining whether the side-to-side gapping present in a chronic knee injury is due to either a medial or posterolateral injury.

Magnetic resonance imaging (MRI) is also useful to diagnose injuries to the medial knee structures and demonstrate the location of damaged structures. Coro-

FIGURE 4. Photograph of a right knee demonstrating the central arm of the posterior oblique ligament. Abbreviations: AMT, adductor magnus tendon; MGT, medial gastrocnemius tendon; POL, posterior oblique ligament; SM, semimembranosus tendon; sMCL, superficial medial collateral ligament.

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LaPradeRF,Wijdicks CA.The ManagementofInjuriesto the MedialSide oftheKnee.JOrthop Sports Phys Ther 2012;42(3):221-233

Anatomía

• LCMp• Fémur:12.5mmdistalaLCMs• Tibia:3.2mmdistalalasuperficiearticular

DiscussionThe study quantitatively determined the morphology ofthe MCL (sMCL, dMCL). The ligament length and itsinsertion areas on the femur and tibia were measuredupon dissection of cadaveric human knees in full

extension. We found that the sMCL was triangular inshape and the proximal and distal parts were composedof parallel fibers, whereas the middle part of the sMCLwas composed of parallel and oblique fibers. We foundthat the widths of proximal and distal parts were similar

Figure 4 Posteromedial corner of the knee. (A). Photograph showing the posterior portion of the sMCL was firmly attached to the medialmeniscus of the knee (right knee); (B). the anterior portion of the sMCL was cut and everted, the posterior portion of the sMCL was connect tothe meniscus.

Figure 5 Dissected deep medial structures of the knee. (A). Cadaveric view of the femoral and tibia attachment of medial structures of theknee (left knee); (B). Schematic diagram illustrating the length and width of the meniscofemoral ligament and meniscotibial ligament. MM =medial meniscus, MFL = meniscofemoral ligament, MTL = meniscotibial ligament.

Liu et al. Journal of Orthopaedic Surgery and Research 2010, 5:69http://www.josr-online.com/content/5/1/69

Page 5 of 8

224 | march 2012 | volume 42 | number 3 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]near full knee extension.

The results of these quantitative, anatomic, and clinically relevant biome-chanical studies were used to develop an anatomic medial knee reconstruc-tion technique that reconstructs the 2 divisions of the superficial MCL and the posterior oblique ligament.4 Data from sectioning studies with buckle transduc-ers attached to the reconstruction grafts indicate that anatomic reconstruction re-stores native stability to the medial knee and does not result in overconstraint, which could lead to overloading of the grafts and their eventual failure. The data also demonstrate that the normal load-sharing relationships among the medial knee structures were restored with this reconstruction technique (FIGURE 6).4

DIAGNOSIS OF MEDIAL KNEE INJURIES

History

Almost all patients with medial knee injuries present with a history of having sustained a contact or

noncontact valgus stress to the knee. Lo-calized pain and swelling along the me-niscofemoral or meniscotibial division of the medial knee structures are sometimes reported. For athletes with grade III me-dial knee injuries, subjective complaints of side-to-side instability can often be ascertained from their medical histories.

ClassificationThe classification of medial knee inju-ries is primarily based on the amount of medial compartment gapping present with an applied valgus stress during the clinical examination or a valgus stress radiograph, performed or taken at 20° of knee flexion. The American Medical Association’s grading scale is most com-monly utilized to classify the severity of injuries.3 It is important to recognize that this is a subjective grading scale based on the perceived amount of gapping that oc-curs when a clinician performs a valgus stress maneuver on the patient.

In general, a grade I tear presents

with localized pain along the medial knee structures and no significant medial com-partment gapping. An isolated grade II medial knee injury also presents with lo-calized pain along the medial knee struc-tures, but also demonstrates significant gapping with a definite end point pres-ent. A grade III, or complete, medial knee injury is present when there is no defined end point after application of a valgus stress at 20° of knee flexion. Historically, the gap sizes corresponding with grade I, II, and III injuries have been reported to be 0 to 5 mm, 6 to 10 mm, and greater than 10 mm, respectively, compared to the uninjured contralateral knee.1,10,15,21,22 However, it is important to recognize that studies published after the Ameri-can Medical Association guidelines were initially proposed have demonstrated that the actual amounts of medial com-partment gaps corresponding to grade I, II, and III injuries, when measured ob-jectively against the contralateral knee, are much smaller than the historically accepted values quoted above (TABLE).

Clinical ExaminationPhysical examination of acute medial knee injuries can be very accurate at identifying the location and grade of in-stability. Conversely, the examination of chronic medial knee injuries can often be clinically challenging and requires more objective means of measuring instabil-ity, such as stress radiographs. As part of the initial examination, inspection of the knee for any signs of abrasions, lac-erations, contusions, or localized edema should be performed.14 In addition, pal-pation of the meniscofemoral and me-niscotibial divisions of the medial knee structures along their entire lengths can also be very useful to identify the injury location. This is important because dif-ferences in healing potential between me-niscofemoral and meniscotibial medial knee injuries have been reported.6

Valgus stress loads applied to the knee at full extension or at 20° of knee flexion can help estimate the amount of medial compartment gapping (FIGURE 7). For an isolated grade III medial knee injury, a

FIGURE 3. Photograph of the deep medial collateral ligament of a left knee. The superficial medial collateral ligament and the joint capsule anterior and posterior to the deep medial collateral ligament have been removed. The hemostat (bottom) is deep to the meniscofemoral portion of the deep medial collateral ligament, while the forceps (top) is holding the meniscotibial portion of the deep medial collateral ligament. Abbreviations: MM, medial meniscus; SM, semimembranosus tendon (anterior arm).

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LaPradeRF,Wijdicks CA.The ManagementofInjuriesto the MedialSide ofthe Knee.JOrthop Sports Phys Ther 2012;42(3):221-233

Anatomía

• POL• 3ramas?(capsular,centralysuperficial)• Refuerzocapsular• Setensaporaccióndelsemimembranosoenflexión

Anatomía

• POL• Inserciónproximal:7mmdistaly3mmanterioraltubérculoaductor

• Insercióndistal:postero-medialentibia,adyacenteaporcióndirectadelsemimembranoso

a true lateral view was created. The coordinates of thecenter of the sMCL and POL insertions were mapped onsquares in the true lateral view. Then, the positionalrelation of the insertions of the sMCL and POL and therelated osseous landmarks were analyzed.

Results

Macroscopic FindingsThe femoral insertion of the sMCL was located in a

depression distal and anterior to the adductor tubercle

(AT). The apex of the AT could be palpated readily. Themedial epicondyle (ME) was palpated, but its apex wasnot identified clearly because it was flat or shaped like ashallow groove. The gastrocnemius tubercle (GT) waspalpated as the insertion of the gastrocnemius tendon;however, its apex was also not identified clearlybecause of its variable and shallow shape. The femoralinsertion of the POL was located posterior to the sMCLand distal to the apex of the AT. The POL runs in a “fan-like” fashion as it courses distally, with the anterior partof the distal POL fibers merging with the fascia cruris

Fig 1. (A) Macroscopic findingswith a medial view of the leftknee showing the superficialmedial collateral ligament(sMCL) (blue string), posterioroblique ligament (POL) (redstring), adductor tubercle (AT),and semimembranosus tendon(SM). (B) Three-dimensionalimage of the medial view of theleft knee showing the recon-structed insertion area of thesMCL and POL and the relatedosseous landmarks. The blueareas show the sMCL insertion,the red areas show the POLinsertion, and the white arrow-heads indicate the tibial crest.

Fig 2. (A) Macroscopic findings with a posterior view of the left knee showing the posterior oblique ligament (POL) insertion andrelated osseous landmarks. The black arrowheads indicate the POL insertion, where it attaches to the semimembranosus tendon (SM)and tibia directly, and the white arrowheads indicate the semimembranosus groove, the bony canal to which the direct arm of the SMattaches. (B)Three-dimensional imageof aposteriorviewof the left knee showing the reconstructed insertionareaof thedirect insertionof the POL (red area), as well as the semimembranosus groove (white arrowheads). (sMCL, superficial medial collateral ligament.)

402 T. SAIGO ET AL.

þÿ D e s c a r g a d o p a r a A n o n y m o u s U s e r ( n / a ) e n C o n s e j e r í a d e S a n i d a d d e M a d r i d B i b l i o t e c a V i r t u a l d e C l i n i c a l K e y . e s p o r E l s e v i e r e n m a y o 0 5 , 2 0 1 8 .Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.

Saigo T.Morphology ofthe Insertions ofthe SuperficialMedialCollateral LigamentandPosteriorObliqueLigament Using 3-DimensionalComputed Tomography:ACadaveric Study.Arthroscopy.2017;33:400-407

DeLong JM,Waterman BR.Surgical Repair ofMedialCollateral Ligament andPosteromedial Corner Injuriesofthe Knee:ASystematic Review.Arthroscopy.2015;31:2249-2255has been limited by a number of notable factors,including poorly defined or inadequately sized patientpopulations, frequency of concomitant ligamentous orother intra-articular trauma, widely variable surgicaltechnique and/or rehabilitation protocols, and insuf-ficient analysis or reporting of published data.8,11

Moreover, inconsistent surgical outcomes and reportsof significant postoperative valgus and anteromedialrotatory instability (AMRI) may reflect the misdiag-nosis or undertreatment of associated medial kneestructures.8 Currently, through a deeper understand-ing of the pathoanatomy, biomechanics, and morenuanced anatomic repairs, we are gaining insight intothe benefit of primary MCL surgical treatment forspecific-patient populations. The aim of this study wasto systematically evaluate the objective clinical out-comes after primary repair of the MCL and PMC of theknee to inform clinical recommendation regarding itsefficacy. On the basis of recent clinical reports byStannard et al.,8 we hypothesized that medial repair ofthe knee would contribute to relatively higher rates ofvalgus instability and suboptimal functional outcomeswith surgical management.

MethodsAfter Institutional Review Board exemption, a sys-

tematic review was conducted to identify all publicationsdescribing repair of the MCL and PMC of the knee. Acomprehensive literature search was performed using acomputer-based search of the Medline/PubMed Data-base (U.S. National Library of Medicine, National In-stitutes of Health) from 1966 to August 14, 2014. Theelectronic database algorithm search was not limited bystudy design or language of publication and intentionallyused broad terms to maximize capture of literature. Thefollowing terms were used as keywords and medicalsubject headings and appeared in the title, abstract orkeyword fields: (“MCL” OR “POL” OR “Medial CollateralLigament, Knee” OR “posterior oblique ligament” OR“medial collateral ligament”) AND (“knee” OR (“knee”OR “knee” OR “knee joint” OR (“knee” AND “joint”) OR“knee joint”) OR “knee joint”) AND (“wound healing”OR (“wound” AND “healing”) OR “wound healing” OR“repair”) AND (“humans”).Study selection for inclusion in the systematic review

was determined by examining the title and/or abstract ofall articles obtained from the database search. Exclusion

Fig 1. Medial and posteromedial ligament anatomy of the knee, (A) superficial and (B) deep. AMT, adductor magnus tendon;MG, medial gastrocnemius muscle; MGT, medial gastrocnemius tendon; POL, posterior oblique ligament; SM, semimembranosusmuscle; sMCL, superficial medial collateral ligament; VMO, vastus medialis obliquus muscle.

2250 J. M. DELONG AND B. R. WATERMAN


• Biomecánica– Restrictor delvalgoderodilla

• LCMs,porciónproximal

– Restrictor delaRotaciónExterna(Dial?)• LCMs,porcióndistal

– Restrictor delaRotaciónInterna• POL• LCMs,porcióndistal

Griffith CJ,Wijdicks CA,LaPradeRF,Armitage BM,Johansen S,Engebretsen L.Forcemeasurements on the posterioroblique ligament andsuperficialmedialcollateralligament proximalanddistaldivisions to applied loads.AmJSports Med.2009;37:140– 148.

• Biomecánica

• LCMs principalrestrictor delvalgoapartirde30ºdeflexión

• POLPrincipalrestrictor delvalgoentre0ºy30ºdeflexión

Griffith CJ,Wijdicks CA,LaPradeRF,Armitage BM,Johansen S,Engebretsen L.Forcemeasurements on the posterioroblique ligament andsuperficialmedialcollateralligament proximalanddistaldivisions to applied loads.AmJSports Med.2009;37:140– 148.

• RelaciónconLCA

Bollier M,SmithPA.AnteriorCruciate Ligament andMedialCollateral LigamentInjuries.JKnee Surg 2014;27:359–368.

andMCL repair, or early ACL reconstruction and nonoperativetreatment of MCL injury. The following treatment algorithmpresents general principles to guide decision making. In highdemand individuals or high-level athletes, we recommend

earlyACL reconstruction and acuteMCL repair within 2weeksof injury when the patient has a grade 3 MCL injury withincreased medial joint space opening with valgus stress at 0and 30 degrees of knee flexion (physical examination andstress radiography) (►Fig. 5a–i). Although there are reports ofknee stiffness, we start early knee ROM and have not typicallyencountered this problem. In addition, early MCL repair andACL reconstruction are considered in cases of high-levelathletes with grade 3 MCL injury and tibial sMCL avulsionor significant valgus bone bruise pattern onMRI. Delayed ACLreconstruction is performedwhen a grade 1 or 2MCL injury ispresent (no opening with valgus stress in extension). Surgeryis scheduled for 6 to 8 weeks after the injury. The ACLreconstruction is performed and the medial knee is thenre-examined both clinically and arthroscopically with valgusstress testing. Residual medial compartment drive-thru signor a high-riding medial meniscus after ACL reconstruction isindications to perform amedial knee repair. If valgus stabilityhas been restored, then nothing more is done. If the patient

Fig. 4 Intraoperative photo of a high-riding medial meniscus indi-cating a meniscotibial lesion.

Fig. 5 A 17-year-old high school quarterback with valgus knee injury. He had a positive Lachman test and valgus opening in both 0 and 30 degreesof knee flexion. (a) and (b) show the ACL injury and ACL tear bone bruise pattern. (c) and (d) show the femoral-sided MCL injury and valgus bonebruise pattern. (e) shows an outside-in drilling of the femoral-sided ACL tunnel. (f) and (g) show the femoral and tibial ACL tunnels. (h) shows anintraoperative radiograph after ACL reconstruction. The patient had residual medial compartment opening with an intraoperative valgus stresstest after the ACL reconstruction was completed (i) and medial-sided repair with suture anchors of the femoral avulsion was completed. ACL,anterior cruciate ligament; MCL, medial collateral ligament.

The Journal of Knee Surgery Vol. 27 No. 5/2014

ACL and MCL Injuries Bollier, Smith 363

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• Biomecánica– RelaciónLCMp conextrusiónmeniscal

El-KhouryGY,UstaHY,BergerRA.Meniscotibial (coronary)ligament tears.Skeletal Radiol.1984;11(3):191-6.

AydıngözÜ,DemirhanM,GümüşT,ErçakmakB,BeşerCG,Kösemehmetoğlu K,DemiryürekD.Association ofMedialMeniscus Extrusion With the Prominence ofaFascicular Capsulofemoral BandSubjacent to the DeepMedialCollateral Ligament.AJRAmJRoentgenol.2016Apr;206(4):810-6.

Paletta GA

Traumatismo

• Directooindirecto– Valgo– +/- Rotaciónexterna– +/- Flexiónderodilla–MásfrecuenteLCMenlesionesdelLCAporContacto

SalemHS.Contact VersusNoncontact AnteriorCruciate Ligament Injuries:Is Mechanism ofInjury Predictive ofConcomitant Knee Pathology?Arthroscopy.InPress

• Exploración

Exploración

• Doloreninterlinea• Bostezoenvalgo:

– 0º:RoturaasociadadeLCA– 20º:másde3.2mm,roturadelLCMs– 20º:másde9.8mm,roturacomplejomedial

• Inestabilidadrotacionalantero-medial– Rodillaa80ºCajónenRE– DialTest.AumentodeREa30ºy90ºdeflexión

Exploración

• LCA+LCM

– MayorLachman

– MayorPivot-Shift

– Cajónantero-medial

• DiagnósticoDiferencial:

– LesióndelCPLvsCPM– (similaraLCAvsLCP)– Sospecharencasoscrónicos– EncasodedudaRx deestrésbilaterales

• Clasificación– AMA

• GradoI:Nobostezo(0-5mm)• GradoII:Bostezocontopefirme(6-10mm)• GradoIII:Bostezosintopefirme(>10mm)

– GradoIIIdeLCMs aperturadesolo3.2mma20º– LesióncompletadeLCMs,LCMp yPOLdalugara>10mm.

LaPradeRF,Bernhardson AS,Griffith CJ,Ma- calena JA,Wijdicks CA.Correlation ofvalgus stressradiographs with medialknee ligament injuries:an invitrobiomechanicalstudy.AmJSports Med.2010;38:330-338.

• PruebasdeImagen

–Rx• FrecuentementeNormal• Segond Invertido• ValorarTeleRx encasoscrónicos

• Rx deEstrés

• RMN

advised. The patient should be educated about avoiding piv-oting motions of the limb on a planted foot.

Once full weight-bearing is permitted at the seven-weekmark, special attention must be paid to the restoration ofnormal gait mechanics. Also, the therapist must observe thatthe return to full weight-bearing is tolerated and that an ef-fusion does not develop. A persistent effusion in the joint cancontribute to quadriceps muscle inhibition and negate theprogress made with strengthening. The therapist must observethe gait pattern closely to ensure that the patient is not em-ploying a quadriceps-avoidance pattern with a hyperextensionthrust at the knee joint during stance phase. It is also criticalthat the patient avoid posting the foot of the surgically treatedextremity lateral to the base of support in stance in an attemptto unload the joint. This movement pattern increases thevalgus moment at the knee joint, potentially compromisingthe grafts. Provided that lower-extremity strength, motion,and proprioception have been appropriately regained, joggingand basic plyometric and agility exercises may be initiated atsixteen to twenty weeks postoperatively. The patient must beable to tolerate 1 to 2 mi (1.6 to 3.2 km) of brisk walkingwithout a limp and demonstrate adequate kinematic controlwith single-limb squatting prior to initiating an interval jog-ging program. Once the patient has completed this rehabili-tation program without problems, the surgeon can talk to the

patient about returning to full activity if appropriate strengthis noted on functional testing and objective knee stability isobserved on clinical examination. A similar rehabilitationprotocol is implemented after a medial knee reconstruction incombination with an anterior cruciate ligament reconstruc-tion, although there is a longer delay before a full return toactivity.

Confounding VariablesThe so-called Pellegrini-Stieda syndrome is typically diagnosedwith the use of anteroposterior plain radiographs and is char-acterized by intraligamentous calcification in the region of thefemoral attachment of the medial collateral ligament caused bythe chronic tear of the ligament (Fig. 9)74. Treatments to alle-viate pain over the sites of mild and moderate cases of post-traumatic heterotopic ossification of the superficial medialcollateral ligament have been reported to include local corti-costeroid injection and range-of-motion exercises75. Operativeexcision of the calcification and treatment of the chronic tear inthe medial collateral ligament can be considered for more se-vere cases75,76.

Another confounding variable is the presence of con-current injuries, which can obscure the findings of the physicalexamination24. If a primary operative repair or reconstruc-tion is indicated in the presence of multiple-ligament

Fig. 7

Proton-density-weighted magnetic resonance image showing an acute avulsionof the superficial medial collateral ligament and the meniscotibial division of thedeep medial collateral ligament off their tibial attachments. A trabecular mi-crofracture of the lateral epicondyle, most likely caused by an impaction force,can be seen. The arrowhead indicates the distal attachment of the superficialmedial collateral ligament, which has been avulsed from its tibial attachment.

1275

TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 92-A d NU M B E R 5 d M AY 2010IN J U R I E S T O T H E ME D I A L CO L L AT E R A L LI G A M E N T A N D

AS S O C I AT E D M E D I A L ST RU C T U R E S O F T H E K N E E

• RMN

• RMN

• RelaciónconLCA– 78%delesionesGIIIdelLCMpresentanroturasdelLCA.

– 6,8%deroturasdeLCAtienenGIIIdeLCM– 60%dereconstruccionesdelLCMasocianreconstruccióndelLCA

Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin OrthopRelat Res 1978;(132): 206–218

Varelas AM.MedialCollateral Ligament Reconstruction inPatients With MedialKnee Instability.Orthop JSportsMed.2017;5:1-8

BatesNA.Characteristics ofinpatient anteriorcruciate ligament reconstructions andconcomitant injuries.KneeSurg Sports TraumatolArthrosc.2016.Sep;24(9):2778-86

• RelaciónconLCA–LaseccióndelLCM:

• AumentalatensiónenelLCAduranteelvalgoderodilla

• Aumentalatraslaciónanteriora90º(Cajón)

Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale fortreatment. Clin Orthop Relat Res 1978;(132): 206–218

• RelaciónconLCA

– LesionesdelLCMGIIesfactorderiesgoparainestabilidadresidualtraslareconstruccióndelLCA

JiHyun Ahn JH,LeeSH.Risk factors for knee instability after anteriorcruciate ligamentreconstruction.Knee Surg Sports Traumatol Arthrosc (2016)24:2936–2942

• RelaciónconLCA

– Peroeltratamientoquirúrgicoprecozdeambaslesionespuedeaumentarelriesgoderigidez…

Shelbourne KD,Porter DA.Anteriorcruciate ligament-medial collateral ligament injury:nonoperative management ofmedialcollateral ligament tearswith anteriorcruciateligament reconstruction.Apreliminary report.AmJSports Med 1992;20(3):283–286

• RelaciónconLCA

– ¿PodemosusarIsquiotibiales Autólogos paralareconstruccióndelLCAenestoscasos?

• NOafectaatraslaciónanterior

• PeroSIaumentaelValgo

Should the IpsilateralHamstrings BeUsed for AnteriorHerbort M.Cruciate Ligament Reconstruction intheCaseofMedialCollateral Ligament Insufficiency? AmJSports Med.2016;45:819-825

JTKremen.The Effect ofHamstring Tendon Autograft Harvest on the RestorationofKnee Stability inthe SettingofConcurrent AnteriorCruciate Ligament andMedialCollateral Ligament Injuries.AmJSports Med.2018;46(1):163–170

• TratamientoConservador

–GradoIIIaislado–Diferentesprotocolos

• ¿Ortesis?• ¿Limitacióndeextensión?

–Generalmentebuenosresultados– 6-7semanas

Wijdicks CA,Griffith CJ,Johansen S,Enge- bretsen L,LaPradeRF.Injuriesto the medialcollateral

ligament andassociated medialstructures ofthe knee.JBone Joint Surg Am.2010;92:1266-1280.

J.Petermann,T.yon Garrel,L.Gotzen.Non-operative treatment ofacute medialcollateralligament lesions ofthe knee joint.Knee urg Sporst Traumatol Arthrosc 1993;1:93-96

• TratamientoConservador–LCMGIII+LCA

•Tto conservador6-7semanas.•ReconstruccióndeLCA

Wijdicks CA,Griffith CJ,Johansen S,Enge- bretsen L,LaPradeRF.Injuriesto the medialcollateral

ligament andassociated medialstructures ofthe knee.JBone Joint Surg Am.2010;92:1266-1280.

Narvani A,Mahmud T,Lavelle J,WilliamsA.Injury to the proximaldeepmedialcollateral

ligament:aproblematical subgroup ofinjuries.JBone Joint Surg Br2010;92(7):949–953

• TratamientoConservador– LCMGIII

• Inestabilidadresidual.• MayorincidenciadefracasosdelLCA• Artrosisprogresiva

Kannus P.Long-term results ofconservatively treated medialcollateral ligament injuriesoftheknee joint.Clin Orthop Relat Res.1988Jan;(226):103-12.

Kannus P,JärvinenM.Osteoarthrosis inaknee joint due to chronic posttraumatic insufficiency ofthe medialcollateral ligament.Nine-year follow-up.Clin Rheumatol.1988Jun;7(2):200-7.

• TratamientoConservador– LCMGIII+LCA–AumentalatensiónsobrelareconstruccióndeLCApudiendoaumentarlaincidenciadefracasodelaplastia

BattagliaMJ2nd.Medialcollateral ligament injuries andsubsequent loadon the anteriorcruciate ligament:abiomechanical evaluation inacadaveric model.AmJSports Med 2009;37:305–311.

Ma CB.Interactionbetween the ACLgraft andMCLinacombined ACL+MCLknee injury using agoatmodel.ActaOrthop Scand.2000Aug;71(4):387-93.

Kanamori A.JOrthop Sci.2000;5(6):567-71. In-situforceinthemedialandlateralstructuresofintactandACL-deficientknees.

• TratamientoQuirúrgico

• Medialcollateral ligament andposteromedialcorner reconstruction techniques vary andindications arenot clear

Lubowitz JH,2015

• TratamientoQuirúrgicoLCA+LCMGIII

– Lesionesmultiligamentarias queafectanalLCM– LuxacióndeRodilla– Fragmentoóseoavulsionado– LesióndeStener– LCMdistalincarcerado enlaarticulación– Lesionesabiertas– Deportistasdealtademanda– Genu valgo


– ReconstruccióndiferidadelLCA,trascuracióndelLCM

– ReconstrucciónagudaaisladadelLCA– ReconstrucciónagudadelLCAyLCM

LesiónAguda

• LCMs:–Reparar/Aumentar/Reconstruir

• LCMp:Reparar(arpones)• POL:

• -Reparar/Aumentar/Reconstruir


Wijdicks CA.SuperficialMedialCollateral Ligament Anatomic Augmented RepairVersusAnatomic Reconstruction.An InVitroBiomechanical Analysis.AmJSports Med2013;41:2858-2866

Biomechanical Testing

Each knee’s passive flexion path was determined from 0!(or full extension) to 90! by selecting zero force locationsalong the flexion path in 1! increments. For each flexionangle, forces and torques in the remaining 5 DOF wereminimized (\5 N and \0.5 N!m, respectively), while anaxial force of 10 N was applied to ensure contact betweenthe femur and tibia. The passive path tibiofemoral posi-tions were recorded and used as the starting points for sub-sequent biomechanical testing.

For biomechanical testing, robotic force and positioncontrol were used to replicate clinical examinationsthrough a range of flexion angles.9,30 All examinationswere performed at 0!, 20!, 30!, 60!, and 90! of knee flexion.Valgus rotation was measured during a 10-N!m valgus tor-que applied to the tibia.11 Medial gapping was determinedby calculating increases in the translation at the center ofthe medial compartment of the tibiofemoral joint duringapplied valgus torques compared with the intact state.25

The center of the medial compartment of the tibial plateauwas calculated as equidistant between the center of the tib-ial plateau and the medial-most palpable point of the tibiaat the joint line, which was based on the position usedclinically to measure valgus stress radiographs.25

Additionally, rotation limits of the knees were measuredwith applied 5-N!m internal rotation and 5-N!m externalrotation torques.2,4,12 Rotational laxity in response to com-bined rotatory motion was tested with a simulated pivotshift, consisting of a coupled 10-N!m valgus torque followedby a 5-N!m internal rotation torque, and with a coupled88-N anterior drawer force and a 5-N!m external rotationtorque.8,22,33,42 Each testing series was repeated on theintact (Figure 1A), sectioned, and augmented/recon-structed states (Figure 1, B and C). The flexion angle test-ing order was randomized between specimens to preventincremental testing bias.

Surgical sMCL Sectioning Technique

The anatomic attachment sites of the sMCL on the femurand tibia were identified through the superficial incisionand marked with a surgical marking pen.38 After intactstate testing, the sMCL was excised between its femoraland distal tibial attachments, leaving the distal tibialattachment remnant intact, for the sectioned state, whichsimulated a grade 3 sMCL injury before an augmentedrepair or reconstruction.39 The posterior oblique ligamentand deep MCL were left intact.

Figure 1. Anteromedial view of left knee. (A) The superficial medial collateral ligament (sMCL) is shown with the location of the femoralorigin and the proximal and distal tibial insertions of the sMCL. Also displayed are the pes anserine tendons (sartorius, gracilis, andsemitendinosus) coursing distally to their insertion on the tibia anterior to the distal sMCL insertion. Further note the sartorius fascia over-lying the distal sMCL. (B) Anatomic augmented repair of the sMCL in a left knee. Distal tibial fixation of the semitendinosus was per-formed with 2 double-loaded suture anchors by suturing the semitendinosus to the sMCL remnant 6 cm distal to the joint line. Thesemitendinosus tendon was passed deep to the sartorius fascia. Anatomic fixation of the femoral tunnel 3.2 mm proximal and4.8 mm posterior to the medial epicondyle was performed with 60 N of traction applied to the graft at 20! of knee flexion and neutralrotation. Proximal tibial fixation was located 12 mm distal to the joint line and directly over the most anterodistal attachment of the ante-rior arm of the semimembranosus. (C) Anatomic reconstruction of the sMCL. Femoral and distal tibial fixation achieved with an inter-ference screw. Proximal tibial fixation performed with a suture anchor 12 mm distal to the joint line. Arrowheads in (B) and (C) highlightdifferences between the anatomic augmented repair and anatomic reconstruction techniques. VMO, vastus medialis obliquus.

2860 Wijdicks et al The American Journal of Sports Medicine

at National Dong Hwa University on March 31, 2014ajs.sagepub.comDownloaded from

Knee Medial Collateral Ligament and Posteromedial CornerAnatomic Repair With Internal Bracing

James H. Lubowitz, M.D., Gordon MacKay, M.D., and Brian Gilmer, M.D.

Abstract: An internal brace is a ligament repair bridging concept using braided ultrahighemolecular-weight poly-ethylene/polyester suture tape and knotless bone anchors to reinforce ligament strength as a secondary stabilizer afterrepair and return to sports, which may help resist injury recurrence. An internal brace may provide augmentation duringknee medial and posteromedial corner anatomic repair. In patients with combined, chronic, symptomatic anterior cruciateligament (ACL)eposteromedial corner laxity, combined ACL reconstruction with posteromedial corner reconstruction isindicated. Our ACL technique was previously published with video illustration in Arthroscopy and Arthroscopy Techniques.The purpose of this article is to describe, with video illustration, knee posteromedial corner reconstruction using anatomicrepair with internal brace augmentation.

Symptomatic, combined knee ligament injuriesrequire surgical stabilization.1,2 The relevant

anatomic structures that contribute to posteromedialknee stability include the superficial and deep medialcollateral ligaments (MCLs), the posterior oblique liga-ment (POL), and the semimembranosus. In cases ofsymptomatic laxity of the medial side of the knee,posteromedial corner anatomic reconstruction of thesuperficial MCL with or without reconstruction of thePOL using soft-tissue grafts, bone sockets, and inter-ference screw fixation has shown good biomechanicalresults.3,4 However, autografts have morbidity, allo-grafts have risks,2 and bone tunnels with interference

screws sacrifice bone stock, which may be of particularconcern for multiligament reconstructive cases.Alternatively, classic technique for treating the medial

side of the knee laxity is posteromedial corner repair.5,6

In 2014, we propose that such a repair may be benefi-cially augmented with an internal brace. An internalbrace is a tissue repair bridging concept using braidedultrahighemolecular-weight polyethylene/polyestersuture tape and knotless bone anchors to reinforce tissuestrength.An internal brace may provide augmentation during

knee medial and posteromedial corner anatomic repair.Therefore we describe posteromedial corner repair inconcert with augmentation ties. Video 1 demonstratesour technique for knee posteromedial corner repairwith augmentation, described in this report, in a patientwith chronic, severe knee posteromedial corner laxitycombined with anterior cruciate ligament (ACL)insufficiency and anteromedial rotary instability. OurACL technique has been previously published withvideo illustration.7,8 In this technical note, Video 1 fo-cuses on the posteromedial reconstruction.

Surgical TechniqueIn this article, we illustrate knee posteromedial

femoral-sided repair plus internal brace constructionbecause femoral pathology is most common (Figs 1-3).(For tibial laxity, we recommend tibial-sided coronary[meniscotibial] ligament repair in combination withinternal brace augmentation. The tibial technique issimilar to the femoral technique described herein,

From Taos Orthopaedic Institute (J.H.L., B.G.), Taos, New Mexico, U.S.A.;and SportsMed Knee and Shoulder Institute (G.M.), Glasgow, Scotland.

The authors report the following potential conflict of interest or source offunding: J.H.L. receives support from Arthrex, AANA, Breg, Donjoy, Smith &Nephew, Stryker, Taos MRI, Tornier, U&I, Ivivi, Taos Orthopaedic Institute,Taos Center for Sportsmedicine and Rehabilitation. Law firms not related toorthopaedic industry (i.e., medical malpractice defense, ski industry defense).Patents pending with Arthrex, not related to manuscript. G.M. receives sup-port from Arthrex, only as part of consultant agreement for 1 day’s research.Travel paid for 1 day’s research/teaching as part of consultant agreement withArthrex. InternalBrace. Royalties related to internal brace technology. B.G.receives support from Arthrex, Breg, Donjoy, Smith & Nephew, Stryker, TaosCenter for Rehabilitation, Taos MRI, Tornier, U&I.

Received March 29, 2014; accepted May 9, 2014.Address correspondence to James H. Lubowitz, M.D., Taos Orthopaedic

Institute, 1219 Gusdorf Rd, Taos, NM 87571, U.S.A. E-mail: www.newmexicokneesurgery.com

! 2014 by the Arthroscopy Association of North America2212-6287/14265/$36.00http://dx.doi.org/10.1016/j.eats.2014.05.008

Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e505-e508 e505

Knee Medial Collateral Ligament and Posteromedial CornerAnatomic Repair With Internal Bracing

James H. Lubowitz, M.D., Gordon MacKay, M.D., and Brian Gilmer, M.D.

Abstract: An internal brace is a ligament repair bridging concept using braided ultrahighemolecular-weight poly-ethylene/polyester suture tape and knotless bone anchors to reinforce ligament strength as a secondary stabilizer afterrepair and return to sports, which may help resist injury recurrence. An internal brace may provide augmentation duringknee medial and posteromedial corner anatomic repair. In patients with combined, chronic, symptomatic anterior cruciateligament (ACL)eposteromedial corner laxity, combined ACL reconstruction with posteromedial corner reconstruction isindicated. Our ACL technique was previously published with video illustration in Arthroscopy and Arthroscopy Techniques.The purpose of this article is to describe, with video illustration, knee posteromedial corner reconstruction using anatomicrepair with internal brace augmentation.

Symptomatic, combined knee ligament injuriesrequire surgical stabilization.1,2 The relevant

anatomic structures that contribute to posteromedialknee stability include the superficial and deep medialcollateral ligaments (MCLs), the posterior oblique liga-ment (POL), and the semimembranosus. In cases ofsymptomatic laxity of the medial side of the knee,posteromedial corner anatomic reconstruction of thesuperficial MCL with or without reconstruction of thePOL using soft-tissue grafts, bone sockets, and inter-ference screw fixation has shown good biomechanicalresults.3,4 However, autografts have morbidity, allo-grafts have risks,2 and bone tunnels with interference

screws sacrifice bone stock, which may be of particularconcern for multiligament reconstructive cases.Alternatively, classic technique for treating the medial

side of the knee laxity is posteromedial corner repair.5,6

In 2014, we propose that such a repair may be benefi-cially augmented with an internal brace. An internalbrace is a tissue repair bridging concept using braidedultrahighemolecular-weight polyethylene/polyestersuture tape and knotless bone anchors to reinforce tissuestrength.An internal brace may provide augmentation during

knee medial and posteromedial corner anatomic repair.Therefore we describe posteromedial corner repair inconcert with augmentation ties. Video 1 demonstratesour technique for knee posteromedial corner repairwith augmentation, described in this report, in a patientwith chronic, severe knee posteromedial corner laxitycombined with anterior cruciate ligament (ACL)insufficiency and anteromedial rotary instability. OurACL technique has been previously published withvideo illustration.7,8 In this technical note, Video 1 fo-cuses on the posteromedial reconstruction.

Surgical TechniqueIn this article, we illustrate knee posteromedial

femoral-sided repair plus internal brace constructionbecause femoral pathology is most common (Figs 1-3).(For tibial laxity, we recommend tibial-sided coronary[meniscotibial] ligament repair in combination withinternal brace augmentation. The tibial technique issimilar to the femoral technique described herein,

From Taos Orthopaedic Institute (J.H.L., B.G.), Taos, New Mexico, U.S.A.;and SportsMed Knee and Shoulder Institute (G.M.), Glasgow, Scotland.

The authors report the following potential conflict of interest or source offunding: J.H.L. receives support from Arthrex, AANA, Breg, Donjoy, Smith &Nephew, Stryker, Taos MRI, Tornier, U&I, Ivivi, Taos Orthopaedic Institute,Taos Center for Sportsmedicine and Rehabilitation. Law firms not related toorthopaedic industry (i.e., medical malpractice defense, ski industry defense).Patents pending with Arthrex, not related to manuscript. G.M. receives sup-port from Arthrex, only as part of consultant agreement for 1 day’s research.Travel paid for 1 day’s research/teaching as part of consultant agreement withArthrex. InternalBrace. Royalties related to internal brace technology. B.G.receives support from Arthrex, Breg, Donjoy, Smith & Nephew, Stryker, TaosCenter for Rehabilitation, Taos MRI, Tornier, U&I.

Received March 29, 2014; accepted May 9, 2014.Address correspondence to James H. Lubowitz, M.D., Taos Orthopaedic

Institute, 1219 Gusdorf Rd, Taos, NM 87571, U.S.A. E-mail: www.newmexicokneesurgery.com

! 2014 by the Arthroscopy Association of North America2212-6287/14265/$36.00http://dx.doi.org/10.1016/j.eats.2014.05.008

Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e505-e508 e505

except that placement of the primary anchor and therepair are performed at the tibial anatomic insertionsand the internal brace is tensioned to a second anchorat the femoral anatomic insertion of the MCL.)For knee posteromedial femoral-sided repair plus in-

ternal brace reconstruction, the skin incision should bestraight when the knee is straight and should extendfrom anterior to the medial femoral epicondyle to apoint 6 cm distal to the joint line, which represents thetibial attachment of the superficial MCL. When theknee is flexed, the incision will curve like a hockeystick, and because the skin flap is posterior, care is takento avoid too posterior of an incision.Deep surgical dissection is then required to identify

the MCL and the POL throughout their full extent.

Digital palpation can be helpful in identifying thefemoral origin of the MCL because it lies just proximaland posterior to the medial femoral epicondyle. ThePOL courses from proximal and posterior to the MCLinsertion in a posteroinferior direction. Relevant tibialanatomic landmarks include the tibial insertion of thesemimembranosus, the pes anserinus, and the distalinsertion of the superficial MCL, 6 cm distal to the jointline, just under the sartorius fascia of the pes.Radiographic landmarks for the femoral MCL are of

great value,9 but careful dissection also clearly de-lineates the MCL femoral insertion without fluoros-copy, even after femoral-sided injury. If there is doubtas to anatomy or isometry, a suture can be wrappedaround guide pins and serve as an isometer during kneerange of motion to ensure correct anatomic position.After careful exposure of the femoral origin,MCL repair

is performed5,6 with suture anchors (SwiveLock 4.75-mm-diameter PEEK [polyether ether ketone] anchors;Arthrex, Naples, FL) loaded with high-strength suture(FiberWire; Arthrex). In larger patients, 2 anchors areused, 1 for theMCL and 1 for the POL. TheMCL and POLare advanced proximally to achieve maximal tissue ten-sion and are repaired anatomically, after decortication ofthe medial femur. To complete the posteromedial repairand to achieve POL plication, it is vital to sew the anteriorborder of the POL to the posterior border of the MCL,advancing the POL from distal to proximal and fromposterior to anterior.The femoral anchor is placed in cancellous bone, so

we simply punch, then tap, and then screw in the an-chor. The tibial anchor is placed in cortical bone, soinsertion requires placement of a 4.5-mm unicorticaldrill hole, then tapping to 4.75 mm, and then screwing

Fig 1. The skin incision forms a straight line when the knee isstraight and extends from anterior to the medial epicondyle to6 cm distal to the joint line (medial view of left knee, wherepatella is superior and hip is to left). The femoral origin of theMCL (F), superficial MCL, POL, and joint line (JL) are noted.

Fig 2. A 4.75 mm SwiveLock anchor has been inserted at thefemoral origin of the MCL (medial view of left knee, wherepatella is superior and hip is to left). The anchor is loaded withNo. 0 FiberWire (upper and lower suture limbs) for MCLadvancement and FiberTape (middle wider suture limbs) forinternal brace construction. The POL is reflected for lateradvancement.

Fig 3. Internal brace (blue arrows) augments superficial MCLreconstruction (medial view of left knee, where patella issuperior and hip is to left). The internal brace is sewn to theproximal tibial periosteum to augment the deep MCL (yellowarrow).

e506 J. H. LUBOWITZ ET AL.

vanderList JP,DiFelice GS.Primary Repair ofthe MedialCollateral Ligament WithInternal Bracing.Arthrosc Tech.2017;6:e933-e937

of the MCL are tensioned to reapproximate theligament toward the femoral MCL origin (Fig 2A). Theknee should be held flexed to 30! to avoid capturing thejoint. After the primary repair of the MCL is completed,the core stitches and repair stitches can be reused toapproximate more superficial tissues as necessary. Oncethey are used to their fullest, the core stitches areremoved, the repair stitches are cut short, and theprimary repair of the ligament is complete. Dependingon the injury pattern, in some cases, the senior author(G.S.D.) prefers to first deploy the suture anchor andthen to suture the MCL from proximal to distal andsuture the ligament toward the suture anchor.

Internal BraceNow, a second minimal skin incision is made over the

distal insertion of the superficial MCL, which is locatedapproximately 6 cm distal to the joint line.12 Dissectionis made through layer 1 to expose the distal fibers of thesuperficial MCL. Care is taken to avoid the hamstringtendons that traverse the exposure. A clamp is placedunder layer 1, and the MCL is followed proximallyunder the skin bridge until the proximal insertion isreached. The clamp is then visualized through theproximal incision wound. The FiberTape is grabbedwith the clamp, is channeled under the skin bridgedistally along the repaired MCL, and exits out of thedistal wound at the distal insertion of the superficialMCL (Fig 2B).The FiberTape now needs to be fixed distally with a

second suture anchor (Fig 3A). By use of a punch tap, ahole is created at the center of the distal MCL insertion,just proximal to the hamstring tendons. The FiberTape isthen passed through the loop of a second 4.75-mmVented BioComposite suture anchor. The suture

anchor is placed at the hole, the FiberTape is tensionedwith the knee at 30! of flexion, and the suture anchor ispartially deployed in the hole. The knee is then testedfor range of motion (ROM) and valgus stability toensure the knee both is stable to valgus and has notbeen overconstrained (Fig 3B). Once satisfactory tensionon the FiberTape is achieved, the suture anchor is fullydeployed in the tibia. The core stitch is removed, theFiberTape is cut short, and the internal bracingprocedure is complete. Finally, the knee is tested forROM and valgus stability at 0! and 30! of flexion, andthe wounds are closed in standard layered fashion. Theadvantage of the internal brace is that the repair isessentially protected, and the patient is able to both bearweight and begin ROM exercises immediately. Pearlsand pitfalls of this technique are shown in Table 1.

Rehabilitation ProtocolPrimary goals of rehabilitation are to obtain early

ROM, prevent stiffness, and normalize gait. Othersignificant injuries, such as an ACL tear, often influencethe exact rehabilitation protocol. In general, patientswear a brace for 4 weeks along with weight bearing astolerated, and the brace is locked in extension untilquadriceps control is regained. In the first few days,ROM exercises are initiated in controlled fashion. After4 to 6 weeks, gentle strengthening is commenced and astandard ACL-MCL rehabilitation program is followed.

DiscussionInjury of the MCL in the setting of ACL injury is

frequently reported, and the optimal treatment of gradeII and III injuries is unclear.1,3-5,7,8 Most surgeons preferconservative treatment for 4 to 6 weeks to let the MCLheal, after which ACL reconstruction is performed.

Fig 3. (A) View on the medial side of a right knee in 20! to 30! of flexion. The FiberTape internal brace is now channeled underthe skin bridge, and a suture anchor (arrow) is used to fix the FiberTape on the anteromedial side of the tibia. The PassPortcannula (hash sign) of the primary anterior cruciate ligament repair can be seen. (B) View on the medial side of a right knee infull extension. The suture anchor is partially deployed in the tibia after the FiberTape has been tensioned (arrow), and the knee isnow ranged through its range of motion to assess any overconstraint of the knee. The PassPort cannula (hash sign) of the primaryanterior cruciate ligament repair can be seen.

PRIMARY MCL REPAIR WITH INTERNAL BRACING e935

Use the 4.5 mm cannulated reamer to drill over the Guide Pin to a depth of 25 mm. Tap the bone socket to the laser line on the 4.75 mm SwiveLock Tap. Note: Incomplete tapping may compromise anchor fixation.

Pass both limbs of the FiberTape through the eyelet of the 4.75 mm BioComposite SwiveLock and insert the anchor. This step occasionally requires a gentle tap with the mallet. Note: Do not overtension. The FiberTape should be slightly looser than the MCL when the repair is complete.

7

Wrap the FiberTape around the 2.4 mm Guide Pin and check for isometry by going through the full range-of-motion. Evaluate the tracking and laxity of the FiberTape throughout the ROM. If any adjustments need to be made, make any tension or positioning adjustments and recheck for isometry.

6

8

ries that may need to be addressed or at least consid-ered in the management plan. An MRI scan is typi-cally obtained to identify the location and extent of theMCL injury, as well as to identify other intra-articularpathology including chondral or meniscal injury. Spe-cifically, a “Stener”-like lesion of the MCL or sublux-ation with entrapment within the joint must be iden-tified.19,38 Surgery is not offered in a standard mannerin the acute phase; however, acute reduction and fix-ation of the displaced distal attachment of the super-ficial MCL are considered in the case where a Stenerlesion of the knee is identified on MRI. Although thereis no high-level evidence to support the acute fixationof these lesions, similar to the classic Stener lesion ofthe thumb, there is reasonable concern that the distalMCL will not heal because of the interposed sartorialfascia and medial hamstring tendons (Level IV and

Level V evidence).19,38,39 Regardless of early surgicaltreatment, the knee is maintained in a ROM brace toprotect against valgus stress. In cases of high-gradeMCL injury, we typically lock the brace in extensionfor weight bearing for approximately 10 to 14 daysafter the injury. ROM limits are set from full exten-sion (preventing hyperextension) to 90° of flexion.The patient completes physical therapy to (1) achieveresolution of the effusion, (2) regain knee extension andflexion ROM, and (3) regain quadriceps muscle tone andstrength. The length of this “pre-rehabilitation” programis dependent on acceptable attainment of the statedgoals and may vary from weeks to months. Typically,a period of at least 6 weeks is preferred to allow timefor grade II and III MCL injuries to heal nonopera-tively, thereby eliminating the need for reconstructionor repair at the time of ACL reconstruction.

FIGURE 1. Algorithm for treatment of combined complete ACL and MCL tears. (ACLR, anterior cruciate ligament reconstruction; EUA,examination under anesthesia; MCLR, medial collateral ligament reconstruction; prehab, pre-rehabilitation; rehab, rehabilitation; XR,radiography.)

119TREATMENT OF COMBINED ACL AND MCL INJURIES


Grant JA,Tannenbaum E,MillerBS,Bedi A.Treatment ofcombined completetears ofthe anteriorcruciate andmedialcollateral ligaments.Arthroscopy 2012;28(1):110–122


– ReconstruccióndeLCAsubaguda.Valorarreparación/reconstruccióndelLCMenfuncióndelbostezoy“drive-through”intraoperatorio trasreconstruccióndeLCA

Grant JA,Tannenbaum E,MillerBS,Bedi A.Treatment ofcombined completetears ofthe anteriorcruciate andmedialcollateral ligaments.Arthroscopy 2012;28(1):110–122

Bollier M,SmithPA.AnteriorCruciate Ligament andMedialCollateral LigamentInjuries.JKnee Surg 2014;27:359–368.


– BuenosresultadosenreconstruccióndeLCA+LCMencasoscrónicos

Simultaneous Reconstruction of the Anterior Cruciate Ligament and Medial Collateral Ligament inPatients With Chronic ACL-MCL Lesions. A Minimum 2-Year Follow-up Study. Am J Sports Med.2014;42:1675-1681


GalloRA.Combined AnteriorCruciate Ligament andMedialCollateral Ligament ReconstructionUsing aSingleAchilles Tendon Allograft .Arthroscopy Techniques,Vol 6,No5(October),2017:ppe1821-e1827

1 until the fibers of the superficial MCL are encoun-tered and traced to their proximal attachment. Fluo-roscopy assists in identifying the MCL’s femoralattachment (Fig 7). Radiographic landmarks for thefemoral insertion of the MCL are well documented.10

To determine the isometry of tunnel placement, a su-ture is held at the tibial tunnel entrance and passedaround the guidewire, and the knee is taken through arange of motion. If the suture does not lengthen duringranging, the guidewire is located at the isometric point.If not, the guide pin location is modified until isometryhas been attained. Once the femoral attachment site isconfirmed, the Beath Pin guidewire is passed from thispoint across the distal femur. The guidewire is projectedproximally and anteriorly to avoid penetration of thenotch and the ACL tunnel.The soft tissue portion of the graft is swung proxi-

mally over the wire to (1) identify the length of graftneeded and (b) confirm isometry of the graft (Fig 8). Apoint 25 mm beyond the guidewire is marked andexcess graft excised (Fig 9A). The soft tissue remainingbeyond the guidewire represents the graft that will bedocked into the femoral socket. A no. 2 FiberWire su-ture (Arthrex, Naples, FL) is woven through thisportion of the graft and with both suture tails exitingthe end of the graft (Fig 9B).

The native MCL remaining around the guidewire issplit longitudinally 1 cm proximally and 2 cm distally toallow graft recession. An 8-mm-diameter acorn reameris used to create a 25-mm-long femoral socket. A loo-ped suture is passed through the tunnel across thecondyle to facilitate graft passage.A curved clamp is passed distally within layer 2 superfi-

cial to the native MCL. Once visible within the distal inci-sion, the clamp is opened to create a subcutaneous tunnelfor the graft. The graft sutures are grasped and used to passthe graft subcutaneously and into the femoral socket(Fig 10). The graft is tensioned with a laterally directedforce with the knee flexed to 30!, cycled, and, with a varusforce applied, secured using an interference screw. Pearlsand pitfalls of the technique are listed in Table 1.

Postoperative RehabilitationPostoperatively, the patient is nonweightbearing for

3 weeks followed by partial weightbearing in an extensionbrace for the next 3 weeks. The patient is prescribed pro-phylactic anticoagulant for 2 weeks. Physical therapyincluding gentle range of motion begins at 2 weeks withmotion progression to 90! of flexion by 6 weeks and fullflexion by 10 weeks. At 6 weeks postoperatively, fullweightbearing begins and thehinged brace is replacedwith

Fig 7. Once the incision had been made, more precise localization of the native MCL attachment site is confirmed using fluo-roscopic intersection of the posterior cortex with the Blumensaat line. (MCL, medial collateral ligament.)

Fig 8. Right medial knee,exterior view. Isometry isconfirmed by passing the graftover the wire and taking theknee through flexion (A) andextension (B). If placedisometrically, the graft shouldnot slide or bunch on the wire.

e1824 R. A. GALLO ET AL.


ZhangH.Tibialinlay reconstruction ofthe medialcollateral ligament using Achilles tendonallograft for the treatment ofmedialinstability ofthe knee. Knee Surg Sports Traumatol Arthrosc(2014)22:279–284

sMCL is sutured to the anterior arm of the semimembr-

anosus tendon to repair the proximal division of the sMCL.

After the MCL was fixed, the subcuticular layer, fascia and

skin were closed in layers. The sMCL was placed in the

appropriate layer of the medial aspect of the knee. We

confirmed the position of the MCL with a comparison ofthe pre- and postoperative MRI (Fig. 5).

Rehabilitation

For MCL/ACL reconstruction, a brace with 0–60! ofmotion was permitted. From 2 to 6 weeks, full weight

bearing was permitted with an allowed range of 0–90! of

motion. After 6 weeks postoperatively, knee flexion wasencouraged to reach its full range of motion. Controlled

sports activities could be performed from 3 to 6 monthspostoperatively, and a full return to sports was allowed

9–12 months postoperatively, depending on the activity.

For MCL reconstruction combined with PCL reconstruc-tion, the postoperative rehabilitation was more restrictive.

The motion of the knee is restricted to 0–30! for the first 2

weeks with a long leg brace. From 2 to 6 weeks, knee

Fig. 2 a A complete grade-3 MCL tear from a tibial origin, b thedMCL was repaired by this incision. dMCL, deep medial collateralligament; sMCL, superficial medial collateral ligament

Fig. 3 Anatomical site of the MCL tibial insertion. An osteotomewas used to create a cancellous trough on the medial tibia thatmatched the bone block of the Achilles allograft

Fig. 4 a The bone block was inlaid into the trough and fixed with a45-mm cancellous screw and a 14-mm spiked ligament washer at theisometric point on the tibia, b the proximal end of the graft was fixedwith a 10 9 20-mm interference screw in the femoral tunnel

Knee Surg Sports Traumatol Arthrosc (2014) 22:279–284 281

123

sMCL is sutured to the anterior arm of the semimembr-

anosus tendon to repair the proximal division of the sMCL.

After the MCL was fixed, the subcuticular layer, fascia and

skin were closed in layers. The sMCL was placed in the

appropriate layer of the medial aspect of the knee. We

confirmed the position of the MCL with a comparison ofthe pre- and postoperative MRI (Fig. 5).

Rehabilitation

For MCL/ACL reconstruction, a brace with 0–60! ofmotion was permitted. From 2 to 6 weeks, full weight

bearing was permitted with an allowed range of 0–90! of

motion. After 6 weeks postoperatively, knee flexion wasencouraged to reach its full range of motion. Controlled

sports activities could be performed from 3 to 6 monthspostoperatively, and a full return to sports was allowed

9–12 months postoperatively, depending on the activity.

For MCL reconstruction combined with PCL reconstruc-tion, the postoperative rehabilitation was more restrictive.

The motion of the knee is restricted to 0–30! for the first 2

weeks with a long leg brace. From 2 to 6 weeks, knee

Fig. 2 a A complete grade-3 MCL tear from a tibial origin, b thedMCL was repaired by this incision. dMCL, deep medial collateralligament; sMCL, superficial medial collateral ligament

Fig. 3 Anatomical site of the MCL tibial insertion. An osteotomewas used to create a cancellous trough on the medial tibia thatmatched the bone block of the Achilles allograft

Fig. 4 a The bone block was inlaid into the trough and fixed with a45-mm cancellous screw and a 14-mm spiked ligament washer at theisometric point on the tibia, b the proximal end of the graft was fixedwith a 10 9 20-mm interference screw in the femoral tunnel

Knee Surg Sports Traumatol Arthrosc (2014) 22:279–284 281

123


Tandogan NR,KayaalpA.Surgical treatment ofmedialknee ligament injuries: currentindications andtechniques.EOR.volume 1.February 2016

31

SURGICAL TREATMENT OF MEDIAL KNEE LIGAMENT INJURIES

6. Relative indications. Complete tibial side MCL inju-ries in athletes have a worse prognosis for healing and are considered to require surgery by some authors.30 Similarly, surgical treatment of the medial side may be considered for combined ACL and MCL injuries in valgus knees.

Reconstruction of medial injuriesReconstruction of medial knee injuries is indicated for chronic symptomatic medial instability after conservative treatment, or in cases where tissue quality precludes primary repair in acute cases. Historical techniques include a distally-pedicled semimembranosus graft,30 distally-based semitendinosus graft,31 pes anserinus transfer,32 proximal advancement or recession of the MCL on the medial epicondyle,33 and advancement of the tibial insertion of sMCL.34 These have been followed by single or double bundle reconstructions35 using autografts (mostly hamstrings) or allografts.35,36

In a cadaveric study, Wijdicks et al have shown that anatomical augmented repairs and anatomical recon-structions were able to improve knee stability and provide less than 2 mm of medial joint gapping at 0° and 20° of flexion.37 Three treatment options are currently employed for the reconstruction of medial structures; all of them use free tendon grafts fixed at anatomical insertion sites under appropriate tension (Fig. 5).

1. Isolated sMCL reconstructionsThese techniques are indicated in patients with medial lax-ity in flexion. A doubled free hamstring tendon graft is usu-ally preferred. The tendon graft should be placed between the supero-posterior part of the medial epicondyle on the femur and the tibial insertion of sMCL 5–7 cm distal to the

joint line. Leaving the semitendinosus distal insertion intact is not recommended as the anterior insertion of the ham-strings is non-anatomical and does not restore adequate medial stability. Femoral fixation is usually performed in a blind tunnel with an interference screw, while tibial fixa-tion can be achieved with a staple or a button implant on the lateral cortex (Fig. 6).

Large screw/washer combinations should be avoided in the femoral fixation. The distal fixation on the tibia is important as shorter grafts do not provide adequate rota-tional stability.38 Yoshiya et al have reported on the 2-year follow-up of 24 patients using semitendinosus and graci-lis tendons and have found normal or nearly normal IKDC scores in all patients.30 The contralateral patellar tendon was used for ACL reconstruction in this series. Using a similar technique, Kim et al have found less than 2 mm medial laxity in 22 of 24 patients followed for 52 months, with a mean Lysholm score of 91.39

2. Reconstruction of the sMCL and POL using a single femoral tunnelThese techniques are employed in patients with medial laxity in both full extension and 20 degrees flexion. A two-tailed graft is placed in a tunnel on the medial epicondyle. One limb of the graft is fixed distally on the sMCL on the tibia (Fig. 7a) while the other limb is fixed just anterior to the semimembranosus insertion on the tibia to reproduce the POL (Fig 7b). The sMCL graft is fixed in 20 degrees flexion, while the POL graft is tensioned in full extension (Fig. 7).

Lind et al have reported on the 2-year follow-up of 50 patients using this technique. They found that medial lax-ity was less than 5 mm in 98% of the patients, and 74% had IKDC A or B scores.40

Fig. 5 Current medial reconstruction techniques. a) Isolated sMCL reconstruction; b) Reconstruction of the sMCL and POL using a single femoral tunnel; c) Anatomical reconstruction of the sMCL and POL using 4 separate tunnels in the femur and tibia.

a) b) c)

DeLong JM,Waterman BR.Surgical Techniques for the Reconstruction ofMedialCollateral Ligament andPosteromedial Corner Injuriesof the Knee:ASystematicReview.2015;31:2258-2272

Fig 4. Single-bundle medialcollateral ligament reconstruction.

Fig 5. Nonanatomic doublebundle posteromedial cornerreconstruction.

RECONSTRUCTION OF MEDIAL COLLATERAL LIGAMENT 2265


findings are indicated in Table 4. These various tech-niques attempt to use various types of grafts and fix-ation methods. Allografts have the potential risk forcomplications such as infection and irradiation-associated biomechanical degradation, require addi-tional surgical costs, and are not available in somecountries.11 Autograft harvest may further local tissuedamage, risk donor site morbidity, and potentiallyweaken dynamic medial stabilizers when using sem-itendinosus and/or gracillis tendons.41 In addition,autologous tissue may have questionable tissue qualityafter acute knee dislocation. The use of double-bundlegraft constructs8,42,36,39,43-45 increases technicalcomplexity, often resulting in multiple bone tunnelsand different points of fixation with additional hard-ware, which may add bulk to the final construct.11

Triple and quadruple bundle semitendinosus/gracillisautografts involving various looping techniques, figure-of-8, or triangular routing configurations have alsobeen described.8,14,45 Attempts to replicate the nativesMCL anatomy have led to the use of grafts tunneledthrough the tibia in a triangular vector pattern.8,46 Thisinnovative technique may also variably contribute sta-bility through the recreation of the oblique fibers of thecentral arm of the POL and middle portion of the sMCL.However, chronic localized inflammation at the tibialbone-graft interface may result from graft excursionand repetitive shear stress without interference screw

fixation.8 Risk also lies in over-tensioning the centralarm of the POL during graft tunneling, which canretract the posteromedial horn of the meniscus andnegatively affect medial knee stability during flexion.47

Similarly, knee stiffness remains the most commoncomplication after reconstruction of the MCL45 andmay arise from aggressive anterior mobilization of theposteromedial joint capsule into the graft tissue.22

Tendon transfer procedures of the semitendinosustendon obviate the need for allograft tissue and anadditional bone tunnel and fixation site for the sMCLon the distal tibia. However, maintenance of the exist-ing distal semitendinosus insertion results in an exces-sively anterior tibial position for the reconstructedsMCL. Furthermore, LaPrade et al. reported failure ofall MCL grafts during pilot biomechanical testing wheredistal tibial reconstruction tunnels were placed slightlyanterior to the pes anserinus vis-à-vis a more posterioranatomic attachment.1

Techniques using quadriceps tendons,10 bone-patella-tendon-bone,10 and Achilles bone block allograft havebeen widely described, with the bone block fixation inthe femur7,11,48 and tibia.49,50 While the Achilles doesoffer early osseous healing, a broad ligament recon-struction for recreation of the anterior and posterioraspects of the sMCL, and a potentially less-invasive 2-incision technique, it is not a comprehensive anatomicreconstruction because it does not fully restore

Fig 6. Nonanatomic tendontransfer.



DeLong JM,Waterman BR.Surgical Techniques for the Reconstruction ofMedialCollateral Ligament andPosteromedial Corner Injuriesof the Knee:ASystematicReview.2015;31:2258-2272

investigators concluded that a more anatomictechnique effectively restores valgus stability and kneefunction at short-term follow-up.

Nonanatomic Medial Knee Reconstruction. Nonanatomicmedial knee reconstructions were performed in 237patients across 10 studies, including both single- anddouble-bundle techniques (Figs 4 and 5). Of thosereporting medial joint space widening, the cumulativeaverage of patients with a nonanatomic medial kneereconstruction and less than 3 mm on valgus stresswas 79.1% (144 of 182 patients). Kitamura et al.revealed no difference in absolute mean medial jointopening between the operative knee and the intactknee after single-bundle sMCL reconstruction, and86.7% of patients has a valgus opening of less than 3mm versus the contralateral knee.37 Koga et al.performed concomitant MCL and POL repair withsingle-bundle sMCL reconstruction in 18 patients,resulting in an average of 1 mm relative medialopening on radiographic studies and only 1 patientwith widening up to 3 mm.10 Marx and Hetsronishowed similar success with single-bundle Achillesallograft reconstruction of the sMCL; all 14 patients in

this series had firm endpoints on manual valgus stress,with only 3 patients having grade 1þ.11 Similarly,Yoshiya et al. showed excellent results in 24 patientswith a mean stress widening of 0.2 " 0.5 mm aftertriple- or quadruple-looped hamstring sMCLreconstruction with a nonanatomic medial epicondylartunnel.14 These results were also reproduced by Fanelliand Edson in their single-bundle sMCL reconstructionof 7 patients with equivalent side-to-side tension onmanual stress testing.38 Ibrahim and coauthorsrevealed slightly greater laxity in 5 of 15 patients withgrade 1þ laxity on manual examination after sMCLreconstruction with a nonanatomic femoralattachment.35

Using a double-bundle technique with a singlefemoral tunnel, Liu et al. reported a relative increase of1.1 mm medial widening compared with normal, with14 of 16 patients having less than 3 mm on radiographicstress views.7 In a similar technique, Dong et al.revealed a slightly greater mean of 2.9 " 1.2 mm onvalgus stress testing among 56 patients, and 9.4% ofpatients had detectable anteromedial rotatory instabilityon Slocum test postoperatively.8 In a small series of 9patients, Preiss et al. showed that all patients werestable on manual valgus stress after a double-bundletechnique with a single femoral point of fixation.39

Nonanatomic Tendon Transfer Medial Knee Reconstruction.Three studies used a nonanatomic medial knee

reconstruction technique with hamstring tendontransfer (Fig 6) in a total of 142 patients. In 2 studieswith available data, only 52.6% of patients (60 of 114patients) had medial joint spacing widening less than3 mm on valgus stress testing. Kim et al. reportedexcellent results with their double-bundle technique,with an overall average of 1.1 mm and 22 of 24patients demonstrating a side-to-side difference of lessthan 3 mm radiographic stress images.27 Stannard andcolleagues also reported excellent comparative resultsusing his double-bundle technique with graft passagearound the distal semimembranosus tendon. In thisstudy, they showed a 4% failure rate after medialreconstruction (46 of 48 patients), with 2 patientsexperiencing 2þ or greater valgus laxity or instabilityon anteromedial rotatory drawer test.40 Lastly, Lindet al. revealed greater laxity among their cohort afterdouble-bundle reconstruction; only 25 of 50 patientshad radiographic side-to-side valgus widening lessthan 3 mm, although 98% had normal or nearnormal grade on the IKDC valgus stability subscore.13

DiscussionNumerous surgical techniques have been performed

among a diverse range of patients with concurrentknee injuries, making it difficult to correlate techniquevalidity and outcome success (Tables 2 and 3). Key

Fig 3. Anatomic double-bundle posteromedial corner recon-struction. (POL, posterior oblique ligament; sMCL, superficialmedial collateral ligament.)



Fig 4. Single-bundle medialcollateral ligament reconstruction.

Fig 5. Nonanatomic doublebundle posteromedial cornerreconstruction.

RECONSTRUCTION OF MEDIAL COLLATERAL LIGAMENT 2265


SYMPOSIUM: COMPLEX KNEE LIGAMENT SURGERY

Surgical Technique

Development of an Anatomic Medial Knee Reconstruction

Robert F. LaPrade MD, PhD, Coen A. Wijdicks PhD

Published online: 10 September 2011! The Association of Bone and Joint Surgeons1 2011

AbstractBackground The main static stabilizers of the medial

knee are the superficial medial collateral and posterior

oblique ligaments. A number of reconstructive techniqueshave been advocated including one we describe here.

However, whether these reconstructions restore function

and stability is unclear.Description of Technique This anatomic reconstruction

technique consisted of reconstruction of the proximal and

distal divisions of the superficial medial collateral and theposterior oblique ligament using two separate grafts.

Patients and Methods We prospectively followed all

28 patients (19 male, nine females) who had this newreconstruction between 2007 and 2009. The average age

was 32.4 years (range, 16–56 years). There were eight

acute and 20 chronic injuries. All patients presented withside-to-side instability with activities of daily living and

other higher level activities. Minimum followup was

6 months (average, 1.5 years; range, 0.5–3 years). Nopatients were lost to followup.

Results Preoperative International Knee DocumentationCommittee subjective outcome scores averaged 43.5

(range, 14–66) and final postoperative values averaged

76.2 (range, 54–88). Preoperative valgus stress radiographsaveraged 6.2 mm of medial compartment gapping com-

pared with the contralateral normal knee, whereas

postoperative stress radiographs averaged 1.3 mm.Conclusions Early observations suggest this anatomic

reconstruction technique improves overall patient function

and restores valgus instability.

Introduction

Due to the intricate relationships among the superficial

medial collateral ligament and other medial knee stabiliz-

ers, ie, the deep medial collateral ligament and theposterior oblique ligament, an injury to the medial knee

structures should not be identified solely as a ‘‘medial

collateral ligament’’ injury. Because these injuries are socommon, it has not been unusual in the senior partner’s

(RFL) practice to have patients referred to him with

chronic isolated posterolateral corner injuries who were infact misdiagnosed with medial knee injuries and who had

major functional limitations, especially with side-to-side

instability. Thus, we established a collaborative projectwith the University of Oslo to develop an anatomic medial

knee reconstruction technique to better restore the static

function and overall stability to these patients and to allowimmediate postoperative knee motion to decrease the risk

of the postoperative stiffness issues commonly seen with

medial knee surgeries [11]. This involved detailed quanti-tative anatomic studies [9], static biomechanical sectioning

studies [5], assessment of forces in the native medial knee

structures to applied loads [4, 15], and the development andbiomechanical validation of an anatomic medial knee

reconstruction technique [3].

One or more of the authors (RFL, CAW) received funding from theResearch Council of Norway (Grant 175047/D15) and Health EastNorway (Grant 10703604).Each author certifies that his or her institution approved the humanprotocol for this investigation, that all investigations were conductedin conformity with ethical principles of research, and that informedconsent for participation in the study was obtained.

R. F. LaPrade (&), C. A. WijdicksSteadman Philippon Research Institute, The Steadman Clinic,181 West Meadow Drive, Suite 400, Vail, CO 81657, USAe-mail: [email protected]

123

Clin Orthop Relat Res (2012) 470:806–814

DOI 10.1007/s11999-011-2061-1

Clinical Orthopaedicsand Related Research®A Publication of The Association of Bone and Joint Surgeons®

The three main structures that provide stability to the

medial knee are the superficial medial collateral ligament,posterior oblique ligament, and deep medial collateral

ligament. These three structures work together to provide

both primary and secondary static stabilization roles forvalgus, external rotation, and internal rotation stability to

the knee. As part of the development and optimization of

an anatomic medial knee reconstruction technique, weperformed biomechanical studies that included static sec-

tioning studies of the posterior oblique ligament, proximaland distal divisions of the superficial medial collateral

ligament, and meniscofemoral and meniscotibial divisions

of the deep medial collateral ligament [4] and measurementof the forces present on the proximal and distal divisions of

the superficial medial collateral ligament and the posterior

oblique ligament to applied loads in both the intact [5] andsectioned states [14]. The anatomic information was uti-

lized to develop the locations of the medial knee

reconstruction grafts and to place them into anatomiclocations, while the biomechanical studies provided

important information about the static stability and load-

sharing functions of each individual component of themedial knee structures. Biomechanical testing of our

anatomic reconstruction technique then confirmed the

reconstruction grafts restored stability to the medial kneeand the reconstruction grafts had load sharing similar to

that of the native medial knee structures, which indicated

they were not being overconstrained [3] (Appendix 1).We describe a new anatomic medial knee reconstruction

technique based on quantitative anatomy and report our

preliminary findings on knee function and restoration ofstability in patients who had this new reconstruction.

Surgical Technique

This anatomic reconstruction technique consisted of a

reconstruction of the proximal and distal divisions of the

superficial medial collateral and the posterior oblique lig-ament using two separate grafts (Fig. 1). (Appendix 1

illustrates details about the quantitative locations and sur-

gically important landmarks for identification of theindividual structure attachment sites for optimal location of

the reconstruction tunnels.) First, an anteromedial incision

was made along the medial knee, initiating from 4 cmmedial to the patella and extending distally over the mid-

portion of the tibia approximately 7 to 8 cm distal to the

joint line.To expose the distal tibial attachment site of the

superficial medial collateral ligament, the fascial expan-

sion of the sartorius muscle was incised and the gracilisand semitendinosus tendons were exposed. Deep within

the pes anserine bursa, the distal tibial attachment of the

superficial medial collateral ligament was identified(Fig. 2). In all circumstances, we verified this attachment

site was 6 cm distal to the joint line. We also verified this

reconstruction tunnel was placed at the posterior aspect ofthis attachment site, rather than the anterior aspect,

because we found during our pilot testing, when the distal

tibial reconstruction tunnel was placed slightly anterior, allof the reconstruction grafts failed during biomechanical

testing. At this point, an eyelet passing pin was drilledthrough the center of the distal attachment site and

transversely across the tibia. A 7-mm reamer was then

reamed to a depth of 25 mm. In smaller patients, consid-eration may be given to reaming 6-mm tunnels for the

Fig. 1 A diagram of a right kneeillustrates the superficial medial collat-eral ligament (sMCL) and posterioroblique ligament (POL) reconstructiongrafts. Reprinted with permission ofSAGE Publications, Inc, from CoobsBR, Wijdicks CA, Armitage BM,Spiridonov SI, Westerhaus BD, JohansenS, Engebretsen L, LaPrade RF. Anin vitro analysis of an anatomic medialknee reconstruction. Am J Sports Med.2010;38:339–347. Copyright ! 2009,American Orthopaedic Society forSports Medicine.

Volume 470, Number 3, March 2012 Medial Knee Reconstruction Technique 807

123

LesiónCrónica

• TécnicadeLaPrade– 4Túneles– 2Injertos:

• POL:12cm• LCMs:16cm

– Túnelesde7mmdiámetroy25mmprofundidad

recent studies have described that the POL is anatomicallyand functionally distinct from the sMCL.15 The POL con-sists of 3 fascial attachments that extend off of the distalaspect of the semimembranosus tendon, merging with andreinforcing the posteromedial aspect of the joint capsule(Fig. 2A).2,16,17 The 3 attachments have been termed thecapsular, superficial, and the central (tibial) arms.2,16,17 Thecentral arm of the POL attaches to the femur 1.4mm distaland 2.9mm anterior to the gastrocnemius tubercle and7.7mm distal and 6.4mm posterior to the adductortubercle.2

The capsular arm of the POL is a thin fascial expan-sion that extends from the anterior and distal aspects of thesemimembranosus tendon.2,17 The capsular arm attaches tosoft tissue coursing over the MGT, AMT femoral attach-ment, and AMT expansion to the medial gastrocnemius.2,18

The superficial arm of the POL is a thin fascial expressionthat proximally courses medial to the anterior arm of thesemimembranosus, and distally follows the posterior bor-der of the sMCL.2 The superficial arm proximally blendsinto the central arm of the POL, while it runs distally andparallel to the posterior border of the sMCL until it blendsinto the distal tibial expansion of the semimembranosusand its tibial attachment.2,18 Hughston and Eilers15 pro-posed that the central arm of the POL is the most crucial ofthe 3 attachments, because it is the largest and thickest ofthe 3 attachments. It extends from the distal aspect of thesemimembranosus tendon, attaches to and blends into theposterior joint capsule and the posterior medial meniscus,and reinforces the dMCL.2,17 The central arm fibers arefan-like and follow a proximal course, allowing them to bedifferentiated from the sMCL.2

dMCLThe dMCL, or mid-third medial capsular ligament, is

a distinct thickening of the anterior aspect of the medialjoint capsule and is located deep to the sMCL (Fig. 1B).2,5

The dMCL is roughly parallel to the anterior aspect of thesMCL and is comprised of meniscotibial and meniscofe-moral components.2,16 The meniscotibial component isshorter and thicker than the meniscofemoral component,and attaches on average 3.2mm distal to the tibial jointline.2 The meniscofemoral component is longer and thinnerthan the meniscotibial component, and is located approx-imately 15.7mm proximal to the femoral joint line.2

AMTThe AMT inserts in a small depression 3.0 mm pos-

terior and 2.7mm proximal to the adductor tubercle, anddoes not attach directly to the apex of the tubercle.2 A thickposteromedial fascial expansion from the distal aspect ofthe AMT has attachment sites coursing proximal to theMGT and the posteromedial joint capsule (Fig. 3).2 Thevastus medialis obliquus muscle has 2 attachments along athick tendinous sheath of the AMT and along the lateralaspect of the AMT.2 This thick tendinous sheath resides inthe distal-lateral aspect of the AMT, which attaches to themedial supracondylar line.2 The AMT is rarely injured andserves as an important surgical landmark for medial kneeinjuries.2

MPFLThe MPFL is an important stabilizer of the knee which

assists with sustaining the patella in the trochlear groove.19

A study by LaPrade et al2 identified its attachment sites

FIGURE 1. A, Illustration of femoral osseous landmarks and attachment sites of main medial knee structures. B, Photograph showing theexposure of the deep medial collateral ligament (dMCL) and its attachment to the medial femoral condyle and the MM (medialmeniscus). The sMCL attachment to the femur has been removed just above the dMCL (medial view, left knee). AMT indicates adductormagnus tendon; AT, adductor tubercle; GT, gastrocnemius tubercle; ME, medial epicondyle; MGT, medial gastrocnemius tendon;MPFL, medial patellofemoral ligament; POL, posterior oblique ligament; SM, semimembranosus tendon; VMO, vastus medialis obliquusmuscle. Reproduced with permission from LaPrade et al.2

LaPrade et al Sports Med Arthrosc Rev ! Volume 23, Number 2, June 2015

64 | www.sportsmedarthro.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

SYMPOSIUM: COMPLEX KNEE LIGAMENT SURGERY

Surgical Technique

Development of an Anatomic Medial Knee Reconstruction

Robert F. LaPrade MD, PhD, Coen A. Wijdicks PhD

Published online: 10 September 2011! The Association of Bone and Joint Surgeons1 2011

AbstractBackground The main static stabilizers of the medial

knee are the superficial medial collateral and posterior

oblique ligaments. A number of reconstructive techniqueshave been advocated including one we describe here.

However, whether these reconstructions restore function

and stability is unclear.Description of Technique This anatomic reconstruction

technique consisted of reconstruction of the proximal and

distal divisions of the superficial medial collateral and theposterior oblique ligament using two separate grafts.

Patients and Methods We prospectively followed all

28 patients (19 male, nine females) who had this newreconstruction between 2007 and 2009. The average age

was 32.4 years (range, 16–56 years). There were eight

acute and 20 chronic injuries. All patients presented withside-to-side instability with activities of daily living and

other higher level activities. Minimum followup was

6 months (average, 1.5 years; range, 0.5–3 years). Nopatients were lost to followup.

Results Preoperative International Knee DocumentationCommittee subjective outcome scores averaged 43.5

(range, 14–66) and final postoperative values averaged

76.2 (range, 54–88). Preoperative valgus stress radiographsaveraged 6.2 mm of medial compartment gapping com-

pared with the contralateral normal knee, whereas

postoperative stress radiographs averaged 1.3 mm.Conclusions Early observations suggest this anatomic

reconstruction technique improves overall patient function

and restores valgus instability.

Introduction

Due to the intricate relationships among the superficial

medial collateral ligament and other medial knee stabiliz-

ers, ie, the deep medial collateral ligament and theposterior oblique ligament, an injury to the medial knee

structures should not be identified solely as a ‘‘medial

collateral ligament’’ injury. Because these injuries are socommon, it has not been unusual in the senior partner’s

(RFL) practice to have patients referred to him with

chronic isolated posterolateral corner injuries who were infact misdiagnosed with medial knee injuries and who had

major functional limitations, especially with side-to-side

instability. Thus, we established a collaborative projectwith the University of Oslo to develop an anatomic medial

knee reconstruction technique to better restore the static

function and overall stability to these patients and to allowimmediate postoperative knee motion to decrease the risk

of the postoperative stiffness issues commonly seen with

medial knee surgeries [11]. This involved detailed quanti-tative anatomic studies [9], static biomechanical sectioning

studies [5], assessment of forces in the native medial knee

structures to applied loads [4, 15], and the development andbiomechanical validation of an anatomic medial knee

reconstruction technique [3].

One or more of the authors (RFL, CAW) received funding from theResearch Council of Norway (Grant 175047/D15) and Health EastNorway (Grant 10703604).Each author certifies that his or her institution approved the humanprotocol for this investigation, that all investigations were conductedin conformity with ethical principles of research, and that informedconsent for participation in the study was obtained.

R. F. LaPrade (&), C. A. WijdicksSteadman Philippon Research Institute, The Steadman Clinic,181 West Meadow Drive, Suite 400, Vail, CO 81657, USAe-mail: [email protected]

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Clin Orthop Relat Res (2012) 470:806–814

DOI 10.1007/s11999-011-2061-1

Clinical Orthopaedicsand Related Research®A Publication of The Association of Bone and Joint Surgeons®

of the higher risk of the reconstruction stretching out if theinjury becomes chronic. To prevent fluid extravasation, a diag-nostic arthroscopy could be helpful either before or after theinitial surgical exposure to identify meniscal tears and the site ofthe deep medial collateral ligament injury. In patients with se-vere medial knee injuries, it may be useful to perform the op-erative approach and identify the injured medial structures priorto fluid extravasation; otherwise, definition of the injury is moredifficult.

Complete medial knee ligament injuries may not alwaysheal. Operative treatment is usually indicated for chronicmedial knee injuries in patients with symptomatic instability,pain, and excessive medial joint gapping. Because of contrac-ture of the ligament ends, the formation of scar tissue, and theloss of the potential for healing that characterize chronic tears,a reconstruction with a hamstring autograft or allograft may berequired. An arthroscopic examination can be performed afterthe initial operative approach to identify and treat intra-articular lesions such as chondral defects or meniscal tears.Various techniques for treatment of medial knee injuries, suchas tendon transfer, advancement and retensioning procedures,and free autograft or allograft tendon reconstructions, havebeen described77-79. However, chronic injuries usually requirecomplete reconstruction of the superficial medial collateraland posterior oblique ligaments because of extensive peri-capsular scar formation.

The operative approaches for medial knee repairs andreconstructions predominantly involve an anteromedial inci-sion40,46,78-82. The proximity of the saphenous nerve to themedial portion of the knee makes the nerve vulnerable toinjury. Disruption of the saphenous nerve at the knee canresult in a spectrum of neuropathy ranging from inconse-

quential sensory loss83 to painful neuralgia84. An anatomicstudy defined the location of the sartorial branch of the sa-phenous nerve and characterized a safe zone for a medial kneereconstruction that avoids compromise of the nerve (Fig.10)85. The sartorial branch of the saphenous nerve coursesslightly posterior to the superficial medial collateral ligamentand the posterior oblique ligament, which are the mostcommonly repaired or reconstructed injured medial kneestructures85,86. Accurate knowledge of the location of the sar-torial branch of the saphenous nerve is necessary to avoidinjury87 while at the same time being able to fully repair orreconstruct the medial knee structures to restore their nativeanatomic state.

AppendixTables listing clinical series of medial knee ligament in-juries reported in the literature and describing rehabili-

Fig. 9

Anteroposterior plain radiograph of a right knee, showingposttraumatic ossification known as the Pellegrini-Stieda

syndrome. This is typically characterized by intraliga-mentous calcification in the region of the femoral medialcollateral ligament attachment (arrowheads).

Fig. 10

Diagrammatic representation of the medial side of the knee andthe course of the saphenous nerve and its sartorial and infra-patellar branches. The distance measurements are in relation tothe described landmarks. (Reproduced, with permission, from:Wijdicks CA, Westerhaus BD, Brand EJ, Johansen S, EngebretsenL, LaPrade RF. Sartorial branch of the saphenous nerve in rela-tion to a medial knee ligament repair or reconstruction. KneeSurg Sports Traumatol Arthrosc. 2009 Oct 27 [Epub ahead ofprint].)

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VO LU M E 92-A d NU M B E R 5 d M AY 2010IN J U R I E S T O T H E ME D I A L CO L L AT E R A L LI G A M E N T A N D

AS S O C I AT E D M E D I A L ST RU C T U R E S O F T H E K N E E

• Insercióntibialdistal

–Parteposteriordelatibia!!

• Fijación:–POL:Extensióncompleta.–LCMs:20ºdeflexión.

• InsercióntibialproximalLCMs:

–Implanteconsuturasapartesblandas(12mmdearticulación)

• Postoperatorio– Descarga6semanas– Evitarrigidez:InsistirenrecuperarROM– 2primerassemanasROMenla“zonasegura”– Limitaractividadesconrotaciónderodillayvalgo

• Conclusiones

– LagranmayoríadelaslesionesdelLCMasociadasaroturasdelLCAdebensertratadasconservadoramenteydiferirlareconstruccióndelLCA.

– PERONOTODAS!!

• Conclusiones– Considerartratamientoquirúrgicoen:

• PatronesconcretosdelesióndelLCM(Stener)• MultiligamentariasyLuxaciónderodilla• Persistenciadeinestabilidadmedialalas6semanas• Valgoy“Drive-Through”intraoperatorio trasreconstruccióndelLCA

¡MUCHASGRACIAS!

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