Tibial inlay reconstruction of the medial collateral ligament using Achilles tendon allograft for the treatment of medial instability of the knee

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction

PURPOSE

Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions.

METHODS

A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified.

RESULTS

The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue.

CONCLUSION

The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue.

LEVEL OF EVIDENCE

IV.

Combined Anterior Cruciate Ligament, Medial Collateral Ligament, and Posterior Oblique Ligament Reconstruction Through Single Tibial Tunnel Using Hamstring Tendon Autografts

Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are the most common type of combined ligamentous injury of the knee. The optimal treatment for these combined injuries is controversial. Combined ACL and MCL-posterior oblique ligament (POL) reconstruction avoids late anteromedial rotatory instability and chronic valgus instability of the knee and decreases the increased stress on the ACL graft. Graft choice (hamstring tendon autograft, quadriceps bone-patellar tendon-bone autograft, or Achilles tendon allograft) and anatomic restoration of the medial and posteromedial corner of the knee are challenges of this combined reconstruction. This article describes a technique that allows combined ACL and MCL-POL reconstruction. The hamstring tendons from the contralateral limb are tripled and used as the ACL graft. The gracilis tendon from the ipsilateral limb is doubled and used as the MCL-POL graft. The semitendinosus tendon of the ipsilateral limb is preserved. After ACL reconstruction, the MCL-POL graft is suspended on the ACL graft at the distal end of the tibial tunnel and the graft limbs are used for open reconstruction of the MCL and POL. Three interference screws (Arthrex, Naples, FL) and 1 metal staple are used for graft fixation of this combined reconstruction.

Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury

PURPOSE

The purpose of this study was to compare knee kinematics and graft forces in anterior cruciate ligament (ACL) reconstruction combined with one of two superficial medial collateral ligament (sMCL) reconstruction techniques (parallel or triangular vector sMCL reconstruction).

METHODS

Twenty porcine knees were divided into two groups (n = 20), parallel or triangular vector sMCL reconstruction, with both groups having anatomic single-bundle ACL reconstruction. The knees were tested under (1) an 89-N anterior tibial load, (2) 4 Nm internal and external rotational tibial torques, and (3) a 7 Nm valgus torque.

RESULTS

With ACL/sMCL co-injuries, single-bundle ACL reconstruction alone does not restore anterior, valgus, and internal stability. Triangular vector sMCL reconstruction better restored anterior stability, and parallel sMCL reconstruction better restored valgus stability.

CONCLUSION

This study showed that single-bundle ACL reconstruction alone was not able to restore anterior tibial translation, valgus rotation, and external rotation of the intact knee with combined ACL and sMCL injuries and sMCL reconstruction was also required. The combined ACL and parallel sMCL reconstruction better restored valgus and external rotation stability, while the combined ACL and triangular vector method better restored anterior tibial translation. With combined ACL and severe sMCL injury, both ligaments should be reconstructed. The two sMCL reconstruction techniques exhibited slightly different kinematics and graft force; however, there was not enough difference to recommend one over the other.

Medial collateral ligament reconstruction using bone-patellar tendon-bone allograft for chronic medial knee instability combined with multi-ligament injuries: a new technique

BACKGROUND

The medial collateral ligament (MCL) is the main static stabilizer of the medial knee. The surgical treatment was recommended in cases with serious medial collateral ligament insufficiency combined with multi-ligament injuries and chronic symptomatic medial instability. Several surgical techniques have been described for the MCL reconstruction, while potential problems including donor site morbidity, complicated procedure, and high risk of femoral tunnel collision were reported. In order to minimize such potential limitations, we describe a new medial reconstruction technique for MCL injury using bone-patellar tendon-bone (BPTB) allograft.

METHODS

A longitudinal incision at the medial knee was made. The centers of femoral and tibial attachments were gained through repeated isometricity test. Then, the bone grooves were made around the femoral and tibial centers. The appropriate BPTB allograft was selected, and both ends were trimmed. The prepared bone blocks were embedded into the grooves and fixed with cancellous screws. The programmed rehabilitation exercises were performed after the operation.

RESULTS

A strong graft and bone-to-bone healing on both femoral and tibial attachment sites were obtained, and femoral tunnel collision during multi-ligament reconstruction was avoided. Satisfactory valgus and rotatory stability were gained.

CONCLUSIONS

This novel MCL reconstruction technique using BPTB allograft can be safely performed, and the clinical outcome was favorable with satisfactory valgus and rotatory stability. More cases and additional follow-up results are needed to verify the overall effect of this technique.

The origin points of the knee collateral ligaments: an MRI study on paediatric patients during growth

PURPOSE

Different femoral origins for both the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) have been reported in the growing skeleton (epiphyseal and metaphyseal). Knowledge about the exact attachment sites is mandatory for anatomically correct reconstruction. This study assesses the femoral origins of the knee collateral ligaments in skeletally immature individuals using magnetic resonance imaging (MRI).

METHODS

MRIs of 336 knee joints (median age 15 years (range 2-18 years), m = 209 and f = 127) were retrospectively analysed to assess the distances between the femoral origins of the MCL and LCL to the distal femoral growth plate. In 175 patients, the body sizes were additionally retrieved from medical records.

RESULTS

Both MCL and LCL ligament origins were invariably located on the epiphysis. Mean MCL origin-growth plate distance was 9.6 mm (SD 2.1 mm; range 2.2-13.6 mm) in boys and 8.6 mm (SD 1.5 mm; range 3.4-12.0 mm) in girls. Mean LCL origin-growth plate distance was 9.3 mm (SD 1.8 mm; range 4.3-13.0 mm) in boys and 8.2 mm (SD 1.5 mm; range 3.4-11.8 mm) in girls. The distance between the growth plate and both collateral ligaments as well as the length of the LCL correlated positively with patients' age and body size (MCL R(2) = 0.673 and 0.556, LCL R (2) = 0.734 and 0.645, LCL length R(2) = 0.589 and 0.741; all p < 0.001).

CONCLUSIONS

During growth, the femoral origins of the MCL and the LCL are constantly located on the distal femoral epiphysis. There is a linear increase in the distances from the ligaments' origins to the growth plate according to age and body size. This new information may be of clinical importance for reconstructive surgery of the knee's collateral ligaments.

Surgical Techniques for the Reconstruction of Medial Collateral Ligament and Posteromedial Corner Injuries of the Knee: A Systematic Review

PURPOSE

To systematically review reconstruction techniques of the medial collateral ligament (MCL) and associated medial structures of the knee (e.g., posterior oblique ligament).

METHODS

A systematic review of Medline/PubMed Database (1966 to November 2013), reference list scanning and citation searches of included articles, and manual searches of high-impact journals (2000 to July 2013) and conference proceedings (2009 to July 2013) were performed to identify publications describing MCL reconstruction techniques of the knee. Exclusion criteria included (1) MCL primary repair techniques or advancement procedures, (2) lack of clear description of MCL reconstruction technique, (3) animal models, (4) nonrelevant study design, (5) and foreign language articles without available translation.

RESULTS

After review of 4,600 references, 25 publications with 359 of 388 patients (92.5%) were isolated for analysis, including 18 single-bundle MCL and 10 double-bundle reconstruction techniques. Only 2 techniques were classified as anatomic reconstructions, and clinical and objective outcomes (n = 28; 100% <3 mm side-to-side difference [SSD]) were superior to those with nonanatomic reconstruction (n = 182; 79.1% <3 mm SSD) and tendon transfer techniques (n = 114; 52.6% <3 mm SSD).

CONCLUSIONS

This systematic review demonstrated that numerous medial reconstruction techniques have been used in the treatment of isolated and combined medial knee injuries in the existent literature. Many variations exist among reconstruction techniques and may differ by graft choices, method of fixation, number of bundles, tensioning protocol, and degree of anatomic restoration of medial and posteromedial corner knee restraints. Further studies are required to better ascertain the comparative clinical outcomes with anatomic, non-anatomic, and tendon transfer techniques for medial knee reconstruction.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies and surgical techniques.

Simultaneous Reconstruction of the Anterior Cruciate Ligament and Medial Collateral Ligament in Patients With Chronic ACL-MCL Lesions: A Minimum 2-Year Follow-up Study

BACKGROUND

In cases of chronic anterior cruciate ligament (ACL)-medial collateral ligament (MCL) lesions, nonoperative treatment of the MCL lesion may lead to chronic valgus instability and rotatory instability. The optimal management for patients who have combined ACL-MCL injuries remains controversial.

PURPOSE

To present a case series of 21 patients who underwent simultaneous ACL-MCL reconstruction with a 2- to 5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From October 2007 to December 2010, a total of 21 patients with chronic ACL-MCL injuries, for which the 2 ligaments were reconstructed during the same surgical procedure, were studied. All patients were available for follow-up for at least 2 years. The International Knee Documentation Committee (IKDC) subjective knee scores, valgus and sagittal stability, anteromedial rotatory stability, range of motion, and complications were assessed both preoperatively and postoperatively.

RESULTS

At follow-up, valgus and sagittal laxity were not observed in any of the patients. The mean medial knee opening was significantly reduced to 0.80 ± 0.96 mm (range, -1.2 to 2.6 mm) postoperatively compared with 8.0 ± 1.3 mm (range, 6.1 to 10.7 mm) preoperatively (P < .01). The mean postoperative side-to-side difference measured with the KT-1000 arthrometer was reduced to 0.8 ± 0.9 mm (range, -1.2 to 2.3 mm) compared with 8.4 ± 1.6 mm (range, 6.2 to 13.2 mm) preoperatively (P < .01). Preoperative anteromedial instability was seen in 71% of patients (15/21), whereas none of the patients had anteromedial rotatory instability at the last follow-up. The mean IKDC subjective score improved overall from 45.3 ± 12.0 (range, 28.7-69.0) preoperatively to 87.7 ± 8.2 (range, 65.5-100.0) at the last follow-up (P < .01). Most patients (20/21) had normal or nearly normal range of motion of the knee joint; only 1 patient (5%) had a limitation of flexion of 15° compared with the contralateral knee at the last follow-up.

CONCLUSION

In patients with chronic ACL-MCL lesions, simultaneous reconstruction of the ACL and MCL can significantly improve the medial, sagittal, and rotatory stability of the knee at short-term follow-up.