Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up

Knee Surgery, Sports Traumatology, Arthroscopy (2021)Cite this article

Abstract

Purpose

Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction.

Methods

This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery.

Results

Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18–52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24–72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001).

Conclusion

Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term.

Level of Evidence

IV

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References

  1. 1.

    Andrews K, Lu A, McKean L, Ebraheim N (2017) Review: medial collateral ligament injuries. J Orthop 14(4):550–554

    Article  Google Scholar 

  2. 2.

    Athwal KK, Willinger L, Shinohara S, Ball S, Williams A, Amis AA (2020) The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically. Knee Surg Sports Traumatol Arthrosc 28:3709–3719

    CAS  Article  Google Scholar 

  3. 3.

    Ball S, Stephen JM, El-Daou H, Williams A, Amis AA (2020) The medial ligaments and the ACL restrain anteromedial laxity of the knee. Knee Surg Sports Traumatol Arthrosc 28:3700–3708

    CAS  Article  Google Scholar 

  4. 4.

    Barrett IJ, Krych AJ, Pareek A, Johnson NR, Dahm DL, Stuart MJ et al (2018) Short- to mid-term outcomes of anatomic MCL reconstruction with Achilles tendon allograft after multiligament knee injury. Knee Surg Sports Traumatol Arthrosc 26(10):2952–2959

    Article  Google Scholar 

  5. 5.

    Bonasia DE, Bruzzone M, Dettoni F, Marmotti A, Blonna D, Castoldi F et al (2012) Treatment of medial and posteromedial knee instability: indications, techniques, and review of the results. Iowa Orthop J 32:173–183

    CAS  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Chahla J, Kunze KN, LaPrade RF, Getgood A, Cohen M, Gelber P et al (2020) The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation. Knee Surg Sports Traumatol Arthrosc 26:1–11

    Google Scholar 

  7. 7.

    Cinque ME, Chahla J, Kruckeberg BM, DePhillipo NN, Moatshe G, LaPrade RF (2017) Posteromedial corner knee injuries: diagnosis, management, and outcomes. JBJS Rev 5(11):e4–e4

    Article  Google Scholar 

  8. 8.

    Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S et al (2010) An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 38(2):339–347

    Article  Google Scholar 

  9. 9.

    DeLong JM, Waterman BR (2015) Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: a systematic review. Arthroscopy 31(11):2258–2272

    Article  Google Scholar 

  10. 10.

    Dold AP, Swensen S, Strauss E, Alaia M (2017) The posteromedial corner of the knee. J Am Acad Orthop Surg 25(11):752–761

    Article  Google Scholar 

  11. 11.

    Dong JT, Chen BC, Men XQ, Wang F, Hao JD, Zhao JN et al (2012) Application of triangular vector to functionally reconstruct the medial collateral ligament with double-bundle allograft technique. Arthroscopy 28(10):1445–1453

    Article  Google Scholar 

  12. 12.

    Elkin JL, Zamora E, Gallo RA (2019) Combined anterior cruciate ligament and medial collateral ligament knee injuries: anatomy, diagnosis, management recommendations, and return to sport. Curr Rev Musculoskelet Med 12(2):239–244

    Article  Google Scholar 

  13. 13.

    Encinas-Ullán CA, Rodríguez-Merchán EC (2018) Isolated medial collateral ligament tears: an update on management. EFORT Open Rev 3(7):398–407

    Article  Google Scholar 

  14. 14.

    Ganko A, Engebretsen L, Ozer H (2000) The Rolimeter: a new arthrometer compared with the KT-1000. Knee Surg Sports Traumatol Arthrosc 8(1):36–39

    CAS  Article  Google Scholar 

  15. 15.

    Gelber PE, Masferrer-Pino À, Erquicia JI, Abat F, Pelfort X, Rodriguez-Baeza A et al (2015) Femoral tunnel drilling angles for posteromedial corner reconstructions of the knee. Arthroscopy 31(9):1764–1771

    Article  Google Scholar 

  16. 16.

    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29(5):600–613

    CAS  Article  Google Scholar 

  17. 17.

    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Neyret P, Richmond JC et al (2006) Responsiveness of the international knee documentation committee subjective knee form. Am J Sports Med 34(10):1567–1573

    Article  Google Scholar 

  18. 18.

    Jokela MA, Mäkinen TJ, Koivikko MP, Lindahl JM, Halinen J, Lindahl J (2020) Treatment of medial-sided injuries in patients with early bicruciate ligament reconstruction for knee dislocation. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06207-x

    Article  PubMed  Google Scholar 

  19. 19.

    Kim SJ, Lee DH, Kim TE, Choi NH (2008) Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Jt Surg Br 90-B(10):1323–1327

    Article  Google Scholar 

  20. 20.

    Kitamura N, Ogawa M, Kondo E, Kitayama S, Tohyama H, Yasuda K (2013) A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries. Am J Sports Med 41(6):1274–1281

    Article  Google Scholar 

  21. 21.

    Kittl C, Robinson J, Raschke MJ, Olbrich A, Frank A, Glasbrenner J et al (2021) Medial collateral ligament reconstruction graft isometry is effected by femoral position more than tibial position. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06420-8

    Article  PubMed  Google Scholar 

  22. 22.

    LaPrade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA (2010) Correlation of valgus stress radiographs with medial knee ligament injuries. Am J Sports Med 38(2):330–338

    Article  Google Scholar 

  23. 23.

    LaPrade RF, Ly TV, Wentorf FA, Engebretsen AH, Johansen S, Engebretsen L (2007) The anatomy of the medial part of the knee. J Bone Jt Surg 89(9):2000–2010

    Article  Google Scholar 

  24. 24.

    LaPrade RF, Wijdicks CA (2011) Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res 470(3):806–814

    Article  Google Scholar 

  25. 25.

    Lee DW, Kim JG (2019) Anatomic medial complex reconstruction in serious medial knee instability results in excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc 28(3):725–732

    Article  Google Scholar 

  26. 26.

    Lind M, Jacobsen K, Nielsen T (2019) Medial collateral ligament (MCL) reconstruction results in improved medial stability: results from the Danish knee ligament reconstruction registry (DKRR). Knee Surg Sports Traumatol Arthrosc 28(3):881–887

    Article  Google Scholar 

  27. 27.

    Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE (2009) Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med 37(6):1116–1122

    Article  Google Scholar 

  28. 28.

    Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J et al (2013) Surgical treatment of subacute and chronic valgus instability in multiligament-injured knees with superficial medial collateral ligament reconstruction using achilles allografts. Am J Sports Med 41(5):1044–1050

    Article  Google Scholar 

  29. 29.

    Mehl J, Otto A, Kia C, Murphy M, Obopilwe E, Imhoff FB et al (2019) Osseous valgus alignment and posteromedial ligament complex deficiency lead to increased ACL graft forces. Knee Surg Sports Traumatol Arthrosc 28(4):1119–1129

    Article  Google Scholar 

  30. 30.

    Moatshe G, Brady AW, Slette EL, Chahla J, Turnbull TL, Engebretsen L et al (2016) Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med 45(3):563–569

    Article  Google Scholar 

  31. 31.

    Moatshe G, Vap AR, Getgood A, LaPrade RF, Engebretsen L (2020) Medial-sided injuries in the multiple ligament knee injury. J Knee Surg 33(5):431–439

    Article  Google Scholar 

  32. 32.

    Svantesson E, Hamrin Senorski E, Alentorn-Geli E, Westin O, Sundemo D, Grassi A et al (2019) Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc 27(8):2450–2459

    Article  Google Scholar 

  33. 33.

    Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    Google Scholar 

  34. 34.

    Varelas AN, Erickson BJ, Cvetanovich GL, Bach BR Jr (2017) Medial collateral ligament reconstruction in patients with medial knee instability: a systematic review. Orthop J Sports Med 5(5):2325967117703920

    Article  Google Scholar 

  35. 35.

    Wang X, Liu H, Duan G, Niu Y, Liu C, Wang F (2018) A biomechanical analysis of triangular medial knee reconstruction. BMC Musculoskelet Disord 19:125–125

    Article  Google Scholar 

  36. 36.

    Westermann RW, Spindler KP, Huston LJ, Group MK, Wolf BR (2019) Outcomes of grade III medial collateral ligament injuries treated concurrently with anterior cruciate ligament reconstruction: a multicenter study. Arthroscopy 35(5):1466–1472

    Article  Google Scholar 

  37. 37.

    Wierer G, Milinkovic D, Robinson JR, Raschke MJ, Weiler A, Fink C et al (2020) The superficial medial collateral ligament is the major restraint to anteromedial instability of the knee. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-05947-0

    Article  PubMed  Google Scholar 

  38. 38.

    Willinger L, Shinohara S, Athwal KK, Ball S, Williams A, Amis AA (2020) Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc 28:3720–3732

    Article  Google Scholar 

  39. 39.

    Zhu J, Dong J, Marshall B, Linde MA, Smolinski P, Fu FH (2017) Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surg Sports Traumatol Arthrosc 26(2):550–557

    Article  Google Scholar 

  40. 40.

    Zhu W, Zhu J, Marshall B, Linde MA, Smolinski P, Fu FH (2020) Single-bundle MCL reconstruction with anatomic single-bundle ACL reconstruction does not restore knee kinematics. Knee Surg Sports Traumatol Arthrosc 28(8):2687–2696

    Article  Google Scholar 

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Acknowledgements

The authors acknowledge the assistance received from Dr. Vikram Kakatkar for data collection and Mr. Shrivallabh P. Sane (Lecturer in Biostatistics, Maharashtra Institute of Mental Health, Pune) for the statistical analysis.

Author information

Affiliations

  1. The Orthopaedic Speciality Clinic, 16 Status Chambers, 1221/A Wrangler Paranjpe Road, Pune, 411004, India

    Sachin Tapasvi & Anshu Shekhar

  2. Head, Translational Medicine and Research, SRM Medical College and Hospitals, SRM Institute of Science and Technology, Kattankulathur, Tamilnadu, India

    Shantanu Patil

  3. Consultant Orthopaedic Surgeon, Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada

    Alan Getgood

  4. Department of Surgery, Division of Orthopaedics, University of Western Ontario, London, Ontario, Canada

    Alan Getgood

  5. 3M Centre, University of Western Ontario, London, ON, N6A 3K7, Canada

    Alan Getgood

Authors
  1. Sachin Tapasvi
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  2. Anshu Shekhar
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  3. Shantanu Patil
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  4. Alan Getgood
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Contributions

ST, AS and AG were responsible for conceiving the idea and planning the study. ST and AS were involved in the actual conduct of all surgical procedures. AS and SP performed the data analysis, statistical analysis and prepared the manuscript. AS performed the literature search. ST, SP and AG reviewed and edited the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sachin Tapasvi.

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Conflict of interest

ST: Dr. Tapasvi reports personal fees and paid presentations for Arthrex, Zimmer Biomet and Smith and Nephew; royalties from Jaypee Medical Publishers, New Delhi; and serves on the boards of ISAKOS, APKASS and Indian Arthroscopy Society. All disclosures are outside the submitted work. Anshu Shekhar and Shantanu Patil: None. Alan Getgood: Dr. Getgood reports personal fees from Smith and Nephew and Olympus; research support from Smith and Nephew and Ossur; and royalties from Smith and Nephew and Graymont. All disclosures are outside the submitted work.

Funding

None.

Ethical approval

Institutional Review Board approval from Sahyadri Clinical Research and Development Center obtained prior patient recruitment. Final study results also submitted to the board.

Informed Consent

Informed written consent for participation in the study obtained from all patients.

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Tapasvi, S., Shekhar, A., Patil, S. et al. Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up. Knee Surg Sports Traumatol Arthrosc (2021). https://doi.org/10.1007/s00167-021-06502-1

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Keywords

  • Medial collateral ligament
  • Posterior oblique ligament
  • Anatomic reconstruction
  • MCL reconstruction
  • Valgus stress
  • Stress radiography
  • Functional outcome