Knee

Neal ElAttrache, MD (Los Angeles, CA), demonstrates an MCL reconstruction using a gracilis tendon autograft and the InternalBrace™ technique. Dr. ElAttrache also provides surgical pearls for anchor placement and incorporation of the InternalBrace technique.&nbsp;
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to- bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

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VID1-007966-en-US | A | MCL Reconstruction With Gracilis Autograft, Knee FiberTak® Anchors, and InternalBrace™ Technique

Neal ElAttrache

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

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Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

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MCL Reconstruction With Gracilis Autograft, Knee FiberTak® Anchors, and InternalBrace™ Technique 

Hello, I'm Doctor Neil Alatrash from Los Angeles, and we're going to demonstrate a medial collateral ligament reconstruction and internal brace technique using gracilis tendon autograft and the knee fiber tack anchors. The equipment necessary is the atraumatic hamstring harvester, the fiber tech instrumentation and fiber tacks, and the instrumentation for the 4.75 swivel lock. We have a left knee specimen, and to expose the injured medial collateral ligament and harvest the gracilis tendon, we've made an incision over the medial side of the knee, extending from the medial epicondyle down to a position about three fingers below the anteromedial joint line on the tibia. So you're going to be at the top of the sartorius fascia, the anserine tendons. So we have an incision and dissection of the soft tissue being careful to protect any major branches of the Infrapatellar branch. The saphenous nerve. We've already made an incision in the crural fascia of the knee, and it's beneath that fascia that you'll immediately encounter the medial lateral ligament. We've carried the incision on the fascia down to the sartorius expansion. And just beneath that, the most superior tendon will be the gracilis tendon. To isolate the gracilis tendon for harvesting, we want to keep it attached to its anatomic attachment on the anteromedial tibia. It will be the most superior of the hamstring tendons and directly underneath the sartorius. Expansion, easily isolated. When we get to this layer, we want to be able to bluntly spread and separate a nice path that we'll use for our tendon harvester. Utilization of this gracilis is very user friendly because you don't have to make any separate incision you're going to be able to visualize it through the same incision that you would use to fix your MCL. Now would take a stay suture or Penrose to isolate the gracilis. And then just using your clamp and not scissors, just go ahead and strip up along the tendon. That will detach any firm tendon as fibrous attachments to the gastroc. As you make the turn next using the atraumatic tendon harvester, apply that to our tendon. If you feel any adhesions, then you can simply get underneath the sartorius expansion. And this atraumatic harvester is just like it sounds. It will not prematurely cut off your tendon. Okay, so that's our graft. You really won't know how long of a graft you need, but keeping it attached to the tibia really helps you to control the graph. So you don't have just a free graft you're working with. You don't have to make any drill tunnels that you have to insert the graft. So now we just find the course of the MCL. And MCL is right here going from the medial epicondyle attachment which is here. Here's the anterior border of the MCL, the posterior border of the MCL, and then the fanned posterior oblique ligament behind that. Now we're going to use the drill for the fiber tac anchor. And on this put an anchor immediately at the anterior border of the MCL underneath the sartorius expansion. Since the bone here is cancellous. Going to unwrap those stitches before you pull back on the guide. That will make sure that the bone isn't so hard that you dislodge the anchor. After that is out, then make sure that you set your anchor. Just take that. Stay stitch out of the loops of the stitches in your graft with the anchor well seated. We'll go ahead and place a clamp through both loops of the anchor. We'll pull our gracilis tendon through those. Then, holding tension on the graft, we'll go ahead and secure our loops around the tendon. And we're going to leave those sutures uncut. At this point, I'm going to just make sure we have enough length with this tendon. We have plenty of length. This stage, we would put anchors in along the direction of the native MCL distal to the joint line. What this will do is it will reproduce the attachment of the deep MCL. And for this we separate those stitches. Now, in the post-traumatic situation, this MCL is going to be torn in some fashion. It's either going to be shredded in its mid substance, it's going to be avulsed proximally or avulsed distally. We take this stitch and we're going to go through the substance of the MCL all the way to the posterior border. If the pol is torn too, you can grab some of that as well. So what we're going to do this in mattress fashion. And we save these stitches. Now at this stage we find our attachment. And once again then we make our drill at the attachment for the MCL. To accommodate the double knotless stitch. And then set your anchor. So with the stitch identifying the loops, you can go ahead and separate those loops and then discard the stitch. Now at this stage then we bring our gracilis tendon autograft through those loops again. We have the knee flexed at about 30 degrees, and we have it in a slight figure four position which is closing down the joint. So it's actually reducing the joint with tension applied then to the graph pulling proximally. We go ahead and tighten that down. Once again we'll leave these long for now the MCL to find the proper site of attachment from anterior to posterior on the tibia. The posterior border of the MCL is even with the posterior medial border of the tibia, so that's easily palpable, which is right here, and it's more posterior than you think. So to put this final anchor in, you need to be directed slightly anterior so that you stay in bone, because we'll add an internal brace along with this. We need to measure where we want to attach it. Mark the tendon. We'll use number two fiber wire. And we'll put a Krakow stitch in for about a centimeter in length. We've placed our Krakow sutures over the distal centimeter of the graft and left the stitches long, because we're going to use those stitches to finally fix the graft into its position. And this is a very versatile, because if there was a distal rupture of the MCL that you wanted to add this augmentation, then you could suture the native ligament and use those sutures into the same fixation with the swivel lock as the sutures from the graft. In this situation, what we're going to do, we're going to imagine that the MCL was very deficient and traumatized over a wide length like it often is, and we're going to use the stitches from our proximal anchor as our internal brace sutures. So we find the attachment point and we'll mark that the marking pen. And then this is our our drill for the swivel lock. And then we'll go ahead and tap that as well. So we'll amputate the graft but be a little bit generous and leave some there. So we put all those sutures through the eyelet of a 4.75 swivel lock. And your priority right now is to tension the graft. So take the stitches from the graft and hold those tight. Just take the slack out of the IB stitches. Once you get it started and you're under good tension, then you can just let those stitches go and we fully deploy it. Make sure that we're buried in bone. Nothing proud. And I would save these two. So we have our stitches from from the first loop that we put in that we passed our graph through. Make sure that that that has stayed tight so we can post tension that the stitches that you see here, this is the suture tape, sutures that come off of our proximal anchor. And that's going to function like our internal brace. And we properly want to have that internal brace fixed along the posterior limb of, of the graft, which is the posterior border of the MCL. That way you're going to get full range of motion back. And you'll be able to prevent any laxity in flexion. And we have here we have our graph fixed. Now since we have this late inside the the anchors that we put, we can tie and repair the MCL just distal to the joint line around both limbs of the graft. So we have our internal brace sutures through the eyelet of the swivel lock distally, and we have the central core stitch from the swivel lock. So we'll tie the sutures from the end of the graph to the central core stitch. This further locks the fixation of the graft sutures. And that's our reconstruction. We have both limbs of the graft tension nicely above and below, and also repaired to the native ligament itself. This has been placed anatomically, so it should permit full range of motion with extension and flexion. Once again, you can use your graft and the repaired and supported native ligament as your fixation strut. If you need to tighten the posterior medial capsule and posterior oblique ligament to that. Now, if there has been proximal damage to the ligament near the epicondyle proximal to the joint line, another suture anchor can be added using the fiber tack, once again going through the native collateral ligament complex, even through the medial patellofemoral ligament that sometimes is damaged as well, and so those then can be incorporated into your autograft and native ligament repair and augmentation. So there you have the reconstruction and augmentation of medial collateral ligament with the gracilis tendon autograft and internal brace technique fixation. After we've checked the range of motion and stability, the wound is then closed with a multi-layer closure, closing the deep fascia of the knee and then the subcutaneous tissue and skin.

MCL Reconstruction With Gracilis Autograft, Knee FiberTak® Anchors, and InternalBrace™ Technique

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