Knee

Peter MacDonald, MD (Winnipeg, Canada), demonstrates an onlay medial collateral ligament (MCL) reconstruction using an anterior tibialis allograft tendon, Double Knotless Knee FiberTak® anchors, and the InternalBrace™ technique.
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.

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VID1-007962-en-US | A | MCL Reconstruction Using Knee FiberTak® Anchors and the InternalBrace™ Technique

Peter MacDonald, MD (Winnipeg, MB, Canada)

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.

Operationstechnikvideos

Surgical Technique Videos

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

Vídeos de técnicas cirúrgicas

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

Videos de técnicas quirúrgicas

MCL Reconstruction Using Knee FiberTak® Anchors and the InternalBrace™ Technique

Hi, I'm Doctor Peter McDonnell, an orthopedic surgeon from Winnipeg, Canada, at the Pan Am Clinic and the University of Manitoba. We hope to be able to demonstrate a new technique here for minimally invasive reconstruction of the medial collateral ligament using a tibialis anterior allograft and onlay anchors. I'm here at my back table with a tibialis anterior allograft that's been sutured at either end, and then three double knotless knee fiber tacks, as well as 24.75 swivel lock anchors for the internal brace mechanism on the right. Here we have our exposure of the medial side of the knee. We've marked out the patella and the joint line. We have three incisions. The idea behind that is to minimize the risk of infection and cut down on potential irritation from wounds, rubbing potentially against braces that the patient may wear later. Here we have exposure of the medial femoral epicondyle. And we go just proximal to the flare on the insertion of the MCL. The idea of going proximal is to avoid the graft being too prominent and causing irritation. And then we've passed a link suture down to the superficial MCL insertion distally. And that's just an anterior to the Pez, which is palpated right here six centimeters from the joint line. So you can measure off six centimeters. If you're worried about landmarks here, you can use fluoro to identify your femoral insertion of the MCL. And then we have our posterior medial oblique about one and a half to two centimeters distal to the joint line. And we feel for the flare of the tibia. And again we're going to keep it low profile by just going around the corner on the flare, just keeping the graft less prominent. Here we are going to put our femoral anchor in our knee fiber tack double knotless. And we're going just proximal to the flare to keep things low profile. If you're worried about tunnel convergence or interfering with a PCL tunnel, you're just aiming just midline mid coronal. And I'm just aiming around the flare. It shouldn't with a onlie anchor interfere with any of the tunnels. So we're going to go ahead and put our femoral anchor in. Here we have our NE fiber tack on the femoral side. We've introduced the anchor. We have our two tensioning sutures here. We have a safety suture here. And the loops are ready to go to feed the allograft for the femoral fixation. So we marked the graft here at one third two thirds. That's for the posterior medial oblique on the one third. And the two thirds is the superficial medial collateral. So we're just going to introduce it into the anchor. Tensioning down our sutures. For great fixation on the femoral side especially individuals with good bones such as a young athlete, we're going to preserve the two tape sutures here as internal brace mechanisms, one for the superficial medial collateral and the other for the posterior medial oblique. See, they will pass with the graft down distal. Okay. We're introducing the sutures into the link suture, including the tape for the internal brace for the superficial MCL. And we've passed the link suture through distal. And we're going to pass the graft subcutaneously Easily under the superficial fascia down distal. Okay. So there's the superficial MCL going down to the point six centimetres from the joint line. And we're going to fix that later after we pass our posterior medial oblique band of the MCL. So we have our two limbs, the superficial MCL and the posterior oblique ligament, each with an internal brace passed distally. All right. So we're going to do the fixation now distally for the superficial MCL with the internal brace. We're fixing just the tendon initially. Here we're introducing the double knotless fiber tack anchor distally on the superficial attachment of the MCL just anterior to the pads tendons which you can palpate deep in the incision. Or tensioning the double knotless mechanism. And we have the knee at 30 degrees flexion with a varus stress on the knee through your assistant. As you tension down the two loops to fixate the distal attachment of the superficial MCL. Okay, now that we've fixated the superficial MCL portion, we do have some excess graft. This can be tunneled back under the skin and sutured to the proximal portion to fortify the superficial MCL, especially if you're worried about an extreme laxity situation. We also have the internal brace, which we're going to fixate later with the swivel lock anchor. But first we're going to do the posterior medial oblique portion of the graft. We have the flare of the tibia here. We're going to insert the double knotless knee fiber tack. So for fixation of the posterior oblique ligament just two centimeters distal to the joint line. And we have the flare of the tibia. We're just behind the flare a little bit. So we're going to aim anteriorly so as not to skythe with your anchor. So we're going to drill here. You're also aiming a little bit distal just to stay away from the joint line potentially. Passing the graft through the loop mechanism of the double knotless anchor. And then for this one we're going to go to 60 degrees flexion a little more flexion and a varus stress on the knee. Again as we tension the two loops down. We still have our internal brace sutures for the superficial and the posterior oblique. We're going to fixate those after with the swivel lock anchor. We don't need these as we've tensioned down the posterior oblique. And now we can do independent fixation of the internal brace with the swivel lock anchors. So we're just going to go about 5mm to 1cm anterior to our tibial insertion site and our fixation of the superficial ligament. We'll take the drill for the swivel lock anchor. So for fixation of the internal brace portion of the reconstruction, or about five millimeters anterior and slightly distal, we're aiming straight across, staying away from our previous anchor. It's important to tap these anchors, especially in good bone. Want to tap until the threads are all buried. Going to feed the internal brace through into the swivel lock anchor. And then we're going to go back to the 30 degree flexion and varus stress position. Tension that down. Give it a couple of taps and then insert the anchor. Nice squeak as you go in. Meaning you have good fixation. Want to make sure your anchor is buried so it doesn't stick up? Cause prominence, which can irritate the patient. So you can either either visualize it or feel with a snap. Looks like the anchor is nicely buried. And there we have fixation of our superficial internal brace. We've elected not to double this back in this situation, and we're just going to amputate the distal part of the superficial MCL. And we can close the fascia over top of that. So it shouldn't be prominent. We're now going to go to the posterior oblique ligament. We fixated it already. We're going to do the internal brace portion again just about five millimeters distal. And this time posterior to the anchor that we put in previously with another swivel lock anchor. All right. We're just distal about one centimetre distal to our fixation of the posterior oblique ligament. We're going to put a swivel lock anchor in. For the internal brace mechanism. Tapping this in very good bone in this relatively young specimen. To put the swivel lock anchor in for the internal brace. Again you want to sink the tap completely, especially in this situation where we have very good bone. We don't want the anchor to be prominent and cause irritation later. Inserting the anchor into our tapped hole. We'll have good purchase here. Again, this is 60 degrees of flexion with a varus stress through your assistance. Just making sure the anchor is buried so there's no irritation. And there we have completed our fixation of the internal brace. So we have double fixation for both the superficial and the posterior oblique ligament. And we can amputate the excess graft. Okay. We can trim any excess graph just to make sure it's not going to be prominent. So we've completed our fixation. You want to check your range of motion to make sure the knee goes through. A full range of motion has been captured in terms of the tension of the MCL. Depending on what your other steps or if other ligaments are going to be reconstructed like the ACL, you would do that part of the procedure, but you'd obviously check your laxity at 30 degrees flexion and 60 degrees flexion at the end of the procedure. Post-operative rehab would depend a little bit on what other surgery you would do, but in isolation you'd want to brace these individuals. I allow full range of motion. I don't like stiffness, so I allow full range of motion right away. Feather touch weight bearing for the first three weeks, and then full weight bearing and then wean out of the brace after week six.

MCL Reconstruction Using Knee FiberTak® Anchors and the InternalBrace™ Technique

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