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Comparative Study
. 2024 May;52(6):1505-1513.
doi: 10.1177/03635465241235858. Epub 2024 Mar 29.

A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques

Jobe Shatrov  1   2 , Petra Bonacic Bartolin  1 , Sander R Holthof  1 , Simon Ball  2 , Andy Williams  2 , Andrew A Amis  1
Affiliations
Comparative Study

A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques

Jobe Shatrov et al. Am J Sports Med. 2024 May.

Abstract

Background: There is little evidence of the biomechanical performance of medial collateral ligament (MCL) reconstructions for restoring stability to the MCL-deficient knee regarding valgus, external rotation (ER), and anteromedial rotatory instability (AMRI).

Hypothesis: A short isometric reconstruction will better restore stability than a longer superficial MCL (sMCL) reconstruction, and an additional deep MCL (dMCL) graft will better control ER and AMRI than single-strand reconstructions.

Study design: Controlled laboratory study.

Methods: Nine cadaveric human knees were tested in a kinematics rig that allowed tibial loading while the knee was flexed-extended 0° to 100°. Optical markers were placed on the femur and tibia and displacements were measured using a stereo camera system. The knee was tested intact, and then after MCL (sMCL + dMCL) transection, and loaded in anterior tibial translation (ATT), ER, varus-valgus, and combined ATT + ER (AMRI loading). Five different isometric MCL reconstructions were tested: isolated long sMCL, a short construct, each with and without dMCL addition, and isolated dMCL reconstruction, using an 8 mm-wide synthetic graft.

Results: MCL deficiency caused an increase in ER of 4° at 0° of flexion (P = .271) up to 14° at 100° of flexion (P = .002), and valgus laxity increased by 5° to 8° between 0° and 100° of flexion (P < .024 at 0°-90°). ATT did not increase significantly in isolated MCL deficiency (P > .999). All 5 reconstructions restored native stability across the arc of flexion apart from the isolated long sMCL, which demonstrated residual ER instability (P≤ .047 vs other reconstructions).

Conclusion: All tested techniques apart from the isolated long sMCL graft are satisfactory in the context of restoring the valgus, ER, and AMRI stability to the MCL-deficient knee in a cadaveric model.

Clinical relevance: Contemporary MCL reconstruction techniques fail to control ER and therefore AMRI as they use a long sMCL graft and do not address the dMCL. This study compares 5 MCL reconstruction techniques. Both long and short isometric constructs other than the long sMCL achieved native stability in valgus and ER/AMRI. Double-strand reconstructions (sMCL + dMCL) tended to provide more stability. This study shows which reconstructions demonstrate the best biomechanical performance, informs surgical reconstruction techniques for AMRI, and questions the efficacy of current popular techniques.

Keywords: anteromedial rotatory instability; biomechanical testing; medial collateral ligament; reconstruction techniques.

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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: This study was funded by a grant from Smith & Nephew paid to a research account of Imperial College London. Human tissue samples were obtained from the MedCure Tissue Bank with approval of the Imperial College Healthcare Tissue Bank supported by the National Institute for Health Research and approved by Wales REC3-17/WA/0161. A.W. is a paid speaker for Smith & Nephew and Director of Fortius Clinic London. 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.

Figures

Figure 1.
Figure 1.
Kinematics rig with reflective marker arrays mounted on the femur and tibia for optical tracking. The 2 hanging weights attached to the central pulley induce tibial rotation, and the weight and pulley system attached to the proximal tibia induces anterior tibial translation. Raising the frame with the femur mounted on it causes the knee to extend.
Figure 2.
Figure 2.
Medial collateral ligament (MCL) reconstruction techniques: isolated superficial MCL (sMCL), sMCL + deep MCL (dMCL), isolated dMCL, short construct + dMCL, and isolated short construct.
Figure 3.
Figure 3.
External rotation (deg) under a torque of 5 N·m for the following cases: intact medial collateral ligament (MCL), injury (superficial MCL [sMCL] and deep MCL [dMCL] transected), sMCL reconstruction, sMCL + dMCL reconstruction, dMCL reconstruction, dMCL + short construct, and short construct. Data are presented as mean ± SD for 9 knees.
Figure 4.
Figure 4.
Valgus rotation (deg) under a moment of 8 N·m for the following cases: intact medial collateral ligament (MCL), injury (superficial MCL [sMCL] and deep MCL [dMCL] transected), sMCL reconstruction, sMCL + dMCL reconstruction, dMCL reconstruction, dMCL + short construct, and short construct. Data are presented as mean ± SD for 9 knees.
Figure 5.
Figure 5.
Anterior tibial translation (mm) in response to anteromedial rotatory instability loading (combined 90-N anterior translation force and 5-N·m external rotation torque) for the following cases: intact medial collateral ligament (MCL), injury (superficial MCL [sMCL] and deep MCL [dMCL] transected), sMCL reconstruction, sMCL + dMCL reconstruction, dMCL reconstruction, dMCL + short construct, and short construct. Data are presented as mean ± SD for 9 knees.
Figure 6.
Figure 6.
External rotation (deg) in response to anteromedial rotatory instability testing. Combined 90-N anterior translation force and 5-N·m external rotation torque for the following cases: intact medial collateral ligament (MCL), injury (superficial MCL [sMCL] and deep MCL [dMCL] transected), sMCL reconstruction, sMCL + dMCL reconstruction, dMCL reconstruction, dMCL + short construct, and short construct. Data are presented as mean ± SD for 9 knees.
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