MCL Reconstruction with the Internal Brace Brian D. Busconi, MD - - PowerPoint PPT Presentation

MCL Reconstruction with the Internal Brace

Brian D. Busconi, MD Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center Brian.Busconi@umassmemorial.org

Disclosure

• Consultant

– Arthrex – Mitek

Current MCL Management

• Immobilization
• Stiffness, wasting
• Residual MCL laxity predisposes to loss of ACL graft tension

and rupture

• Recurrent instability leads to OA
• Failed treatment is expensive

Advantages of Internal Brace

• Bridges injured area
• Reestablish normal length
• Allow healing
• Allow early movement
• Minimal soft tissue interference or dissection

Anatomy

• Superficial MCL
• Origin – MFC 3mm proximal/5 mm posterior
• Insertion -6 cm distal to Joint line

– Under Pes anserine

• Biomechanics
• Anterior tight in flexion and extension
• Posterior tight in full extension
• Lax at 30 degrees

Anatomy

• Deep MCL

– Near joint line – medial menicus – Blends with capsule and POL

• Posterior Oblique Ligament

– Adductor tubercle to tibial joint line – Loose in flexion

• Biomechnics

– IR restraint

• Sectioning of Superficial MCL and POL
• Increase Knee IR,ER,Anterior translation,Posterior Translation
• Combined ACL/MCL

– Partial and complete – Increase load on ACL

• Combined injury

– Places ACL at risk

Battaglia et al. AJSM Vol 37, No 2, 2009

My operative indications

• Acute Grade 3 MCL/POL

– Avulsion off tibia – Stener lesion

• Opens grossly at 0 and 30
• Increased ER
• Arthroscope with medial meniscal tear Esp Root
• “drive through sign”

– Significant Laxity

• Hyperlaxity
• Obesity

– High Demand Athlete

My Operative Indications

• Acute grade 3 with combined ligament Injury

– ACL/PCL/Corner Injury – Open at 0 and 30 – Increaesd ER/IR – “Drive Through Sign”

My Operative Indications

• Chronic MCL/POL Injury

– Laprade Technique with reconstruction – Must Evaluate for Mal- alignment

Acute MCL “Drive Through”

• 16 yo soccer player
• ACL/MCL/Root tear

– Opens at 0 and 30 degrees

MCL CL Internal Internal B Brace race

• Incisions
• Proximal – 3mm above and

posterior to epicondyle

• Distal –3-5cm distal to joint
• Few millimeters proximal to

pes anserine and anterior to posteromedial crest of tibia

MCL Internal Brace

• 2.4 mm guide pin
• 4.5 mm reamer
• 4.7 mm tap
• 4.75 mm Bio SwiveLock with FiberTape

MCL Internal Brace

• Place Distal Tibial Pin
• Wrap FiberTape and move the knee
• Fix Distal at 20 degrees, neutral rotation ,slight varus
• Repair the torn MCL

Final Tips

• Ensure the SwiveLock Driver

eyelet is fully inserted into the socket

• Place a hemostat under the

FiberTape to prevent over- constraining

• Repair MCL as Needed

Procedure Complete

• No Gapping even at 30 degrees of flexion with

appropriate Valgus force

• Sufficient stability to allow for early movement

What About Chronic Tears?

• Anatomic reconstruction of

the sMCL and POL

• 4 tunnels, 2 grafts
• Semitendinosus graft split

into 16 cm (MCL) and 12 cm (POL) lengths

• MCL tensioned at 30°
• POL tensioned at 0°

Reestablish sMCL and POL

Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech. 2014 Aug 11;3(4). 1

Advantages of Internal Brace

• Bridges injured area
• Reestablish normal length
• Allow healing
• Allow early movement
• Minimal soft tissue interference or dissection

Conclusions

• Well established track record in the literature
• Eliminates need to rehab MCL prior to ACL reconstruction
• Engineered to brace the MCL at the site of injury
• Minimally invasive, low morbidity
• Affords excellent medial stability in a multi-ligamentous knee