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. 2023 Oct 12;11(10):23259671231202767.
doi: 10.1177/23259671231202767. eCollection 2023 Oct.

Contribution of the Medial Hamstrings to Valgus Stability of the Knee

Pierre-Henri Vermorel  1 , Rodolphe Testa  1 , Antonio Klasan  2   3 , Sven E Putnis  4 , Rémi Philippot  1 , Bertrand Sonnery-Cottet  5 , Thomas Neri  1   6
Affiliations

Contribution of the Medial Hamstrings to Valgus Stability of the Knee

Pierre-Henri Vermorel et al. Orthop J Sports Med. .

Abstract

Background: Multiligament knee injuries involving the medial side are common. When performing surgical reconstruction, use of the medial hamstrings (HS) as grafts remains controversial in this setting.

Purpose: To determine the role of the medial HS in stabilizing the valgus knee for different types of medial-sided knee injury.

Study design: Controlled laboratory study.

Methods: A biomechanical study on 10 cadaveric knees was performed. Valgus load (force moment of 10 N/m) was applied at 0°, 30°, and 60° of flexion, and the resultant rotation was recorded using an optoelectronic motion analysis system. Measurements were repeated for 4 different knee states: intact knee, superficial medial collateral ligament (sMCL) injury, deep medial collateral ligament (dMCL) injury, and posterior oblique ligament (POL) injury. For each state, 4 loading conditions (+ loaded; - unloaded) of the semitendinosus (ST) and gracilis (GRA) tendons were tested: ST+/GRA+, ST+/GRA-, ST-/GRA+, and ST-/GRA-.

Results: At 0° of flexion, combined unloading of the ST and GRA (ST-/GRA-) increased valgus laxity on the intact knee compared with the ST+/GRA+ condition (P < .05). For all medial-sided injury states (isolated sMCL; combined sMCL and dMCL; and combined sMCL, dMCL, and POL damage), ST-/GRA- increased valgus laxity at 0° and 30° of flexion versus ST+/GRA+ (P < .05 for all). The absolute value of valgus laxity increased with the severity of medial-sided ligament injury. Isolated ST unloading increased valgus laxity for the intact knee and the MCL-injured knee (combined sMCL and dMCL) at 0° of flexion (P < .05 vs ST+/GRA+). Isolated unloading of the GRA had no effect on valgus knee stability.

Conclusion: The medial HS tendons contributed to the stabilization of the knee in valgus, and this was even more important when the medial side was severely affected (POL damage). This stabilizing effect was greater between 0° and 30°, in which the POL is the main valgus stabilizer.

Clinical relevance: When deciding on graft selection for multiligament knee injury reconstruction, the surgeon should be aware of the effect of harvesting the medial HS tendon on valgus laxity.

Keywords: MCL; POL; hamstring; knee; multiligament knee injury.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: A.K. has received consulting fees from Stryker and speaking fees from Implantcast. R.P. has received consulting fees from Lepine. B.S.-C. has received consulting fees and royalties from Arthrex. T.N. has received consulting fees from Lepine. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval was not sought for the present study.

Figures

Figure 1.
Figure 1.
Pulley system that permits loading/unloading tendons (sartorius, semimembranosus, gracilis, semitendinosus, quadriceps, biceps femoris). (A) Perspective view. (B) Top view.
Figure 2.
Figure 2.
Experimental protocol. Hamstrings (HS) loading conditions: ST+/GRA+, both semitendinosus and gracilis loaded; ST+/GRA–, isolated semitendinosus loading; ST–/GRA+, isolated gracilis loading; ST–/GRA– both semitendinosus and gracilis unloaded. dMCL, deep medial collateral ligament; POL, posterior oblique ligament; sMCL, superficial medial collateral ligament.
Figure 3.
Figure 3.
Knee valgus laxity (degrees) in function of semitendinous (ST) and gracilis (GRA) loading at 0°, 30° and 60° of flexion for an intact knee. ST+/GRA+, both semitendinosus and gracilis loaded; ST+/GRA–, isolated semitendinosus loading; ST–/GRA+, isolated gracilis loading; ST–/GRA– both semitendinosus and gracilis unloaded.
Figure 4.
Figure 4.
Knee valgus laxity (degrees) in function of semitendinous (ST) and gracilis (GRA) loading at 0°, 30°, and 60° after superficial medial collateral ligament sectioning. ST+/GRA+, both semitendinosus and gracilis loaded; ST+/GRA–, isolated semitendinosus loading; ST–/GRA+, isolated gracilis loading; ST–/GRA– both semitendinosus and gracilis unloaded.
Figure 5.
Figure 5.
Knee valgus laxity (degrees) in function of semitendinous (ST) and gracilis (GRA) loading at 0°, 30° and 60° of flexion after sMCL+dMCL sectioning. dMCL, deep medial collateral ligament; sMCL, superficial medial collateral ligament. ST+/GRA+, both semitendinosus and gracilis loaded; ST+/GRA–, isolated semitendinosus loading; ST–/GRA+, isolated gracilis loading; ST–/GRA– both semitendinosus and gracilis unloaded.
Figure 6.
Figure 6.
Knee valgus laxity (degrees) in function of semitendinous (ST) and gracilis (GRA) loading at 0°, 30°, and 60° of flexion after sMCL+dMCL+POL sectioning. dMCL, deep medial collateral ligament; POL, posterior oblique ligament; sMCL, superficial medial collateral ligament. ST+/GRA+, both semitendinosus and gracilis loaded; ST+/GRA–, isolated semitendinosus loading; ST–/GRA+, isolated gracilis loading; ST–/GRA– both semitendinosus and gracilis unloaded.
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