Minimally Invasive Reconstruction of the Medial Collateral Ligament of the Knee

Document Type : RESEARCH PAPER

Authors

1 Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

2 Cairo Curative Organization, Cairo, Egypt

Abstract

Background: This study describes a minimally invasive technique for the reconstruction of the medial collateral ligament 
(MCL) and posterior oblique ligament (POL) through minimal incisions on the tibial and femoral sides of the ligament 
using the modified Bosworth technique.
Methods: This study included 19 consecutive patients who presented with chronic grade III injury; the mean age was 
29.6 years (standard deviation ± 7.5 years, range 19–43 years), and five patients (26.3%) had no associated injuries. 
Ten patients (52.6%) had associated anterior cruciate ligament (ACL) injury and four patients (21.1%) had associated 
posterior cruciate ligament (PCL) injury. All patients were assessed 18 months postoperatively regarding functional 
outcome using the Lysholm score and medial joint space opening. 
Results: There was a statistically significant improvement in the patient functional outcome as the Lysholm score 
improved from 55.39 ± 6.9 to 89.42 ± 6.4 at 18 months postoperatively. (P< 0.001). At the end of the follow-up, 16 cases 
had grade 1 medial laxity, 3 cases with grade II laxity, and no patients with grade III medial laxity.
Conclusion: Minimally invasive MCL reconstruction with modified Bosworth technique gives very good results 
regarding the functional outcome and residual medial laxity of the knee. 
Level of evidence: IV

Keywords


  1. Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. JBJS. 2010;92(5):1266-80.
  2. Roach CJ, Haley CA, Cameron KL, Pallis M, Svoboda SJ, Owens BD. The epidemiology of medial collateral ligament sprains in young athletes. The American journal of sports medicine. 2014;42(5):1103-9.
  3. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. JBJS. 2007;89(9):2000-10.
  4. Warren LF, Marshall JL, Girgis F. The prime static stabilizer of the medial side of the knee. JBJS. 1974;56(4):665-74.
  5. Athwal KK, Willinger L, Shinohara S, Ball S, Williams A, Amis AA. The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically. Knee surgery, sports traumatology, arthroscopy. 2020;28(12):3709-19.
  6. Griffith CJ, LaPrade RF, Johansen S, Armitage B, Wijdicks C, Engebretsen L. Medial knee injury: part 1, static function of the individual components of the main medial knee structures. The American journal of sports medicine. 2009;37(9):1762-70.
  7. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. JBJS. 1973;55(5):923-40.
  8. Tibor LM, Marchant Jr MH, Taylor DC, Hardaker Jr WT, Garrett Jr WE, Sekiya JK. Management of medial-sided knee injuries, part 2: posteromedial corner. The American journal of sports medicine. 2011;39(6):1332-40.
  9. Petersen W, Loerch S, Schanz S, Raschke M, Zantop T. The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee. The American journal of sports medicine. 2008;36(3):495-501.
  10. Daniel KCM, Stone ML, Hirshman P. The incidence of knee ligament injuries in the general population. American journal of knee surgery. 1991;4:3-8.
  11. Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for treatment. Clinical orthopaedics and related research. 1978 (132):206-18.
  12. Zhang J, Pan T, Im HJ, Fu FH, Wang JH. Differential properties of human ACL and MCL stem cells may be responsible for their differential healing capacity. BMC medicine. 2011;9(1):68.
  13. Chen L, Kim PD, Ahmad CS, Levine WN. Medial collateral ligament injuries of the knee: current treatment concepts. Current reviews in musculoskeletal medicine. 2008;1(2):108-13.
  14. Kannus PE. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clinical orthopaedics and related research. 1988 (226):103-12.
  15. Bonasia DE, Bruzzone M, Dettoni F, Marmotti A, Blonna D, Castoldi F, et al. Treatment of medial and posteromedial knee instability: indications, techniques, and review of the results. The Iowa orthopaedic journal. 2012; 32:173.
  16. Makhmalbaf H, Shahpari O. Medial collateral ligament injury; a new classification based on MRI and clinical findings. A guide for patient selection and early surgical intervention. Archives of bone and joint surgery. 2018;6(1):3.
  17. Hughston JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. The Journal of bone and joint surgery. American volume. 1994;76(9):1328-44.
  18. Kim SJ, Lee DH, Kim TE, Choi NH. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. The Journal of bone and joint surgery. British volume. 2008;90(10):1323-7.
  19. Bosworth DM. Transplantation of the semitendinosus for repair of laceration of medial collateral ligament of the knee. JBJS. 1952;34(1):196-202.
  20. Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, et al. Radiographic identification of the primary medial knee structures. JBJS. 2009;91(3):521-9.
  21. Varelas AN, Erickson BJ, Cvetanovich GL, Bach Jr BR. Medial collateral ligament reconstruction in patients with medial knee instability: a systematic review. Orthopaedic journal of sports medicine. 2017;5(5):2325967117703920.
  22. Bray RC, Fisher AW, Frank CB. Fine vascular anatomy of adult rabbit knee ligaments. Journal of anatomy. 1990; 172:69-79.
  23. Georgiev GP, Iliev A, Kotov G, Kinov P, Slavchev S, Landzhov B. Light and electron microscopic study of the medial collateral ligament epiligament tissue in human knees. World journal of orthopedics. 2017;8(5):372-8.
  24. Loitz-Ramage BJ, Frank CB, Shrive NG. Injury size affects the long-term strength of the rabbit medial collateral ligament. Clinical orthopaedics and related research®. 1997; 337:272-80.
  25. Feeley BT, Muller MS, Allen AA, Granchi CC, Pearle AD. Biomechanical comparison of medial collateral ligament reconstructions using computer-assisted navigation. The American journal of sports medicine. 2009;37(6):1123-30