The medial collateral ligament (MCL) is the main stabilizing structure against valgus force and is a secondary restraint to rotation and posterior translation of the knee. MCL injuries are very common and can be managed nonsurgically because of robust healing capacity, resulting in excellent clinical outcomes. Surgical treatment is recommended for patients with chronic medial instability and MCL injury in combination with multiligament injury. Several surgical techniques exist for the MCL reconstruction, including anatomic and nonanatomic medial knee reconstruction. The MCL consists of the superficial MCL and the deep MCL; however, surgical procedures only allow for reconstruction of the superficial MCL alone or the superficial MCL and the posterior oblique ligament. No surgical procedure allows for reconstruction of the superficial MCL and the deep MCL.

This video demonstrates a novel technique for deep and superficial MCL reconstruction with semitendinosus and gracilis autograft using an adjustable length loop suspensory fixation device for tibial fixation and describes the clinical results of the procedure. The femoral attachment site of the superficial MCL is placed in a depression 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle. The tibial attachment sites of the superficial MCL are placed 14 mm and 60 mm distal to the joint line. The deep MCL consisted of meniscofemoral ligament and meniscotibial ligament relatively thinner than the superficial MCL. The femoral insertion of the deep MCL is placed 20.5 mm proximal to the joint line and below the insertion of the superficial MCL. The tibial insertion of the deep MCL is placed 7 mm from the joint line. Between June 2016 and June 2017, five consecutive superficial and deep MCL reconstruction procedures were performed in patients with chronic medial instability and excessive medial joint opening. Minimum follow up was 1 year. Clinical outcomes were evaluated using the Lysholm Knee Scale score. Medial instability of the knee joint was measured on valgus stress radiographs. The medial joint opening of the surgical knee was compared with that of the contralateral side. The side-to-side difference in medial joint opening was noted in millimeters and used for evaluation.

Stability was divided into four grades according to the International Knee Documentation Committee Subjective Knee Evaluation Form. Normal stability was present if the side-to-side difference was less than 2 mm. Nearly normal stability was present if the side-to-side difference was between 2 mm and 5 mm. Abnormal stability was present if the side-to-side difference was between 5 mm and 10 mm. Severely abnormal stability was present if the side-to-side difference was greater than 10 mm. The mean Lysholm Knee Scale score improved from 66 preoperatively to 93 postoperatively (P < 0.05). The mean medial joint space opening observed on valgus stress radiographs decreased from 8.2 mm preoperatively to 1.5 mm at a follow up of 1 year (P < 0.05). All five of the patients had normal stability according to International Knee Documentation Committee Subjective Knee Evaluation Form. No intraoperative or postoperative complications occurred. Anatomic reconstruction of the superficial and deep MCL with autogenous hamstring tendon using an adjustable length loop suspensory fixation device affords good stability and satisfactory outcomes in patients with medial knee instability.