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Knee Videos: Collateral Ligament
A “Short Isometric Construct” Reconstruction Technique for the Medial Collateral Ligament of the Knee
Recently there has been increased focus on the medial collateral ligament (MCL) and the role the medial ligament complex plays in preventing valgus and external rotation, especially in the setting of a combined ligament injury. Multiple surgical techniques purport to reproduce “normal anatomy”; however, only one technique addresses the deep MCL fibers and the prevention of external rotation. Thus we describe the “short isometric construct” MCL reconstruction which is stiffer than the anatomic reconstructions.Anatomic Combined Anterior Cruciate Ligament and Antero-Lateral Ligament Reconstruction Using Autologous Gracilis and Semitendinosus Graft With Single Tibial and Femoral Tunnel
Anterior cruciate ligament (ACL) injuries are among the most common lesions in orthopaedics practice, but still today, rates up to 24% of unsatisfactory results are reported. Unaddressed anterolateral complex (ALC) injuries have been claimed to be responsible for residual anterolateral rotatory instability (ALRI) after isolate ACL reconstruction and have demonstrated to increase graft failure. In this article, we present our technique for reconstruction of the ACL and anterolateral (ALL) ligament combining the advantages of the anatomical position and the intraosseous femoral fixation to ensure anteroposterior and anterolateral rotational stability.Reefing of the Posteromedial Capsule in Anteromedial Rotatory Instability
The posterior oblique ligament (POL) is the main component of the posteromedial corner (PMC) of the knee and plays a crucial role in acting as a secondary restraint against translation, rotation, and valgus forces. Injuries to the PMC often occur in association with acute or chronic deficiency of the anterior cruciate ligament and may result in anteromedial rotatory instability. A surgical technique for treatment of acute and chronic injuries of the posteromedial structures was first established by Hughston in 1973.Ultrasound-Guided Suture Tape Augmentation and Stabilization of the Medial Collateral Ligament
Management of medial collateral ligament (MCL) injuries usually consists of time and conservative management; however, patients are typically immobilized and need extensive time to return to sport. Although the MCL has been shown to have the ability to heal given time, surgical management is still sometimes needed to provide stability to the knee. Operative techniques vary in methodology, but are typically highly invasive and technically demanding. In the event of multiligamentous or severe injuries, reinforcing the MCL with an ultrahigh-strength, 2-mm-wide suture tape allows for early functional rehabilitation, permitting the native MCL tissue to heal and avoiding late reconstructions.Surgical Management of the Multiple-Ligament Knee Injury
The management of multiligament knee injury is a complex process starting with the adequate identification of the injury. A detailed physical and radiographic examination with a thorough understanding of knee anatomy is crucial to assess all damaged structures: anterior cruciate ligament, posterior cruciate ligament, posteromedial corner including the medial collateral ligament, and posterolateral corner including the lateral collateral ligament. Several surgical techniques have been developed throughout the years to adequately address these ligament insufficiencies.Anatomic Posterolateral Corner Reconstruction With Autografts
Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The LaPrade technique reproduces all 3 main stabilizers. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. We propose a surgical procedure that is a modification of the LaPrade technique using the same tunnel placement, hamstring autografts, and biceps augmentation when necessary.Combined Anterior Cruciate Ligament and Medial Collateral Ligament Reconstruction Using a Single Achilles Tendon Allograft
Approaches to management of combined anterior cruciate ligament (ACL) and high-grade medial collateral ligament (MCL) injuries remain controversial. Some studies suggest that with grade III MCL injuries, patients may benefit from concurrent MCL reconstruction to restore stability and prevent increased stress on the ACL graft. We present a technique for simultaneous ACL/MCL reconstructions using a single Achilles tendon allograft.Combined Anatomic Anterior Cruciate Ligament and Double Bundle Anterolateral Ligament Reconstruction
The results of arthroscopic anterior cruciate ligament (ACL) reconstruction are so far satisfactory and improving over time as a result of the improved understanding of the anatomy and biomechanics of the ACL. Rotational instability confirmed by a positive pivot shift is present in more than 15% of cases who underwent successful ACL reconstruction. Persistent rotational instability interferes with performing pivoting sports, and also may lead to meniscal and chondral injuries, or re-rupture of the reconstructed ACL.Simplifying Anterior Cruciate Ligament Graft Bone Plug Reconstructions: The “U” Trough Technique
This Technical Note discusses an anterior cruciate ligament graft preparation technique to simplify and ease graft visualization, insertion, and fixation. Our technique incorporates a 2-mm central trough in the bone plug of the graft to improve one's ability to efficiently identify and orient the anterior cruciate ligament graft during insertion, and ensure correct screw placement and fixation.Primary Repair of the Medial Collateral Ligament With Internal Bracing
The medial collateral ligament (MCL) is commonly injured in the setting of anterior cruciate ligament (ACL) injuries. Because the MCL has better healing capacity than the ACL, the general perception is that MCL injuries can be treated conservatively. Treating these injuries conservatively, however, can lead to residual valgus laxity. Furthermore, it delays time to surgery, which prevents acute treatment of concomitant ACL injuries using primary repair or acute reconstruction. Several treatment methods for MCL injuries have been proposed, including primary repair, augmented repair with autograft tissue, or primary reconstruction.Combined All-Inside Anterior Cruciate Ligament Reconstruction and Minimally Invasive Posterolateral Corner Reconstruction Using Ipsilateral Semitendinosus and Gracilis Autograft
The anterior cruciate ligament (ACL) is the most commonly injured knee ligament, particularly among adolescents and young adults. Unrecognized posterolateral laxity is understood as a major cause of ACL reconstruction failure, and concomitant injury to the posterolateral corner (PLC) is prevalent and underdetected. We advocate screening all ACL-deficient knees for PLC injury and present a technique combining minimally invasive PLC reconstruction with anatomic all-inside ACL reconstruction. The combined procedure uses only the ipsilateral hamstring tendons representing a major surgical advantage over traditional management approaches.An Alternative Technique to Avoid Injury to the Medial Femoral Condyle When Reaming the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction
Contemporary anterior cruciate ligament reconstruction attempts to replicate the anatomical insertion sites on both the femoral and tibial sides to restore knee stability. Creation of the femoral tunnel by independently reaming through an anteromedial portal may allow surgeons to more reproducibly place the tunnel within the anatomic femoral footprint relative to a transtibial approach. However, inherent to the technique is the risk of iatrogenic injury to the articular cartilage of the medial femoral condyle as the reamers are passed adjacent to the condyle.Identification of the Anterolateral Ligament on Magnetic Resonance Imaging
Studies continue to demonstrate the importance of the anterolateral ligament (ALL) as a secondary restraint in rotational stability of the knee. No clinical exam exists to reliably test the ALL. Advanced imaging allows the surgeon to reliably identify the ALL as an independent structure of the lateral knee. This technique paper provides a reproducible method for identification of the ALL on 3T magnetic resonance imaging based on previously conducted cadaveric dissections of the ligament.Varus-Producing Lateral Distal Femoral Opening-Wedge Osteotomy
Valgus knee alignment in excess of physiological valgus leads to excessive loading of the lateral compartment, which can potentially increase the risk of osteoarthritis and can place the medial knee structures at risk of chronic attenuation. Varus-producing distal femoral osteotomies have been proposed for correction of valgus malalignment, to relieve tension on medial-sided structures, as well as to off-load the lateral compartment. Understanding that symptomatic valgus deformity of the knee represents a complex problem that is magnified in the setting of lateral compartment arthritis or medial ligamentous incompetence, we present our preferred technique for a varus-producing distal femoral osteotomy using plate osteosynthesis and cancellous bone allograft.Anatomic Posterolateral Corner Reconstruction
Posterolateral corner injuries represent a complex injury pattern, with damage to important coronal and rotatory stabilizers of the knee. These lesions commonly occur in association with other ligament injuries, making decisions regarding treatment challenging. Grade III posterolateral corner injuries result in significant instability and have poor outcomes when treated nonoperatively. As a result, reconstruction is advocated. A thorough knowledge of the anatomy is essential for surgical treatment of this pathology.Combined Reconstruction of the Medial Collateral Ligament and Anterior Cruciate Ligament Using Ipsilateral Quadriceps Tendon–Bone and Bone–Patellar Tendon–Bone Autografts
The exclusive autograft choice for medial collateral ligament (MCL) reconstruction that has been described until today is the semitendinosus tendon. However, this has some potential disadvantages in a knee with combined MCL–anterior cruciate ligament (ACL) injury, including weakening of the hamstring's anterior restraining action in an already ACL-injured knee and nonanatomic distal MCL graft insertion when leaving the semitendinosus insertion intact at the pes anserinus during reconstruction. Moreover, because some surgeons prefer to use the hamstring for autologous ACL reconstruction, the contralateral uninjured knee hamstring needs to be harvested as a graft source for the MCL reconstruction if autografts and not allografts are the surgeons' preference.Superficial Medial Collateral Ligament of the Knee: Anatomic Augmentation With Semitendinosus and Gracilis Tendon Autografts
The superficial medial collateral ligament (sMCL) and associated knee structures are the most commonly injured structures of the knee. Most isolated sMCL tears are treated nonoperatively. Several studies have described different algorithms for treatment of sMCL lesions, as well as different types of techniques, both in the acute and in chronic settings. The purpose of this article was to detail our anatomic sMCL augmentation technique using semitendinosus and gracilis tendon autografts.Anatomic Fibular Collateral Ligament Reconstruction
Fibular collateral ligament (FCL) injuries can lead to varus instability of the knee, causing a varus thrust gait and resulting in increased forces on the medial compartment of the knee. In the long term, this can result in meniscal injuries and medial compartment osteoarthritis. Varus instability is also reported to increase forces on the cruciate ligaments, which can lead to overload and failure of these reconstructions in cases of nonrecognized combined injuries. Historically, both repair and reconstruction have been used for grade III injuries to the FCL.Step-by-Step Arthroscopic Assessment of the Anterolateral Ligament of the Knee Using Anatomic Landmarks
New insights into the existence and function of the anterolateral ligament (ALL) of the knee have redirected and refocused attention on the secondary restraints of rotational stability of the knee. The importance of assessing the ALL is increasing, especially in anterior cruciate ligament reconstruction surgery, to decide on the need for an adjunctive extra-articular reconstruction of the ALL to control rotational instability of the knee. However, preoperative assessment of this ligament is difficult.Open Anatomic Reconstruction of the Medial Collateral Ligament and Posteromedial Corner
Injuries to the medial collateral ligament (MCL) and posteromedial corner can occur in isolation or in the setting of multiligamentous knee injuries. Reconstruction of the MCL and posteromedial corner is indicated in the setting of a multiligamentous knee injury. Isolated cases failing nonoperative treatment may also undergo surgical treatment. Our preferred technique for anatomic medial-sided knee reconstruction is an open anatomic MCL reconstruction using an Achilles tendon allograft along with direct repair of all associated medial and posteromedial structures.Anterolateral Extra-articular Soft Tissue Reconstruction in Anterolateral Rotatory Instability of the Knee
Anterolateral rotatory instability (ALRI) occurs after injury to the anterior cruciate ligament (ACL) and the anterolateral structures of the knee. We present a technique for anterolateral extra-articular soft-tissue (ALES) reconstruction of the knee that can be used in revision ACL reconstruction cases, cases of persistent ALRI after adequate ACL reconstruction, and cases with severe ALRI after primary ACL rupture. The surgeon performs ALES reconstruction with a strip of iliotibial tract autograft while respecting the anatomic origin and insertion of the anterolateral ligament.A Technique of Superficial Medial Collateral Ligament Reconstruction Using an Adjustable-Loop Suspensory Fixation Device
This report describes superficial medial collateral ligament reconstruction of the knee using a novel method of graft fixation with the ACL Tightrope RT (Arthrex, Naples, FL). After tibial fixation with either a standard interference screw or staple, femoral fixation of the semitendinosus tendon is performed with the adjustable-loop suspensory fixation device, which allows for both initial graft tensioning and re-tensioning after cyclical knee range of motion. This provides the ability for the graft to accommodate for resultant soft-tissue creep and stress relaxation, thereby allowing for optimal soft-tissue tension and reduction in laxity at the end of the procedure.Arthroscopic Release of the Deep Medial Collateral Ligament to Assist in Exposure of the Medial Tibiofemoral Compartment
Arthroscopy of the knee is a widely used surgical procedure for addressing intra-articular pathology. In assessing the intra-articular structures, visualization is of paramount importance. The medial tibiofemoral compartment is often difficult to fully visualize in tight knees in which limited access can compromise surgical efficacy. Poor visualization can increase the possibility of a residual meniscal tear after attempted partial meniscectomy, as well as the possibility of iatrogenic chondral injury from arthroscopic instruments.Knee Medial Collateral Ligament and Posteromedial Corner Anatomic Repair With Internal Bracing
An internal brace is a ligament repair bridging concept using braided ultrahigh–molecular-weight polyethylene/polyester suture tape and knotless bone anchors to reinforce ligament strength as a secondary stabilizer after repair and return to sports, which may help resist injury recurrence. An internal brace may provide augmentation during knee medial and posteromedial corner anatomic repair. In patients with combined, chronic, symptomatic anterior cruciate ligament (ACL)–posteromedial corner laxity, combined ACL reconstruction with posteromedial corner reconstruction is indicated.Arthroscopic Identification of the Anterolateral Ligament of the Knee
Intense interest has focused on the recent description of the anterolateral ligament of the knee. Advancing knowledge of its anatomy and function is leading to a realization of its importance in the rotatory control of the tibia in anterior cruciate ligament injuries. Reconstruction of this structure will increasingly become an important goal during anterior cruciate ligament reconstruction. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory laxity has poor reproducibility, and it is difficult to define using current imaging techniques.
