The goal of this technique is to create increased distance between the origin and insertion of the lax medial/posteromedial structures. This is done by attaching the lax segments of the tendon/ligament to an adjacent intact structure. Therefore, this procedure is indicated when some medial or posteromedial structures are intact. There are no strict rules regarding the re-tension of lax structures, because this depends on the patient’s injury pattern. However, different structures need to be visualized and probed for tension, and these include the sMCL, the posteromedial capsule, the medial meniscus attachments, the POL, and the capsular arm of the semimembranosus tendon.

The sartorius fascia is incised longitudinally and care is taken to avoid injury to the saphenous nerve. The whole MCL is probed (proximal and distal attachments as well as mid-substance). Once the posteromedial capsule is visualized and palpated for laxity, a longitudinal arthrotomy is performed posterior to the MCL. The capsular arm of the semimembranosus is identified and probed for tension. The POL and the meniscotibial attachments are evaluated. Every lax structure is armed and sutured to an intact adjacent ligament/tendon or back to the bone with transosseous sutures. Multiple reinforcing sutures can be placed across the POL and MCL.

This procedure is indicated when a generalized laxity of the medial/posteromedial structures is present. A medial hockey-stick incision is preferred, from the pes anserinus to the posterior portion of the medial femoral epicondyle. The weakest attachment (femoral or tibial) of the medial/posteromedial complex should be identified. The structures at the weakest attachment must be released as an entire tendon/ligament unit (en masse) and not as individual tendons or ligaments, in order to preserve their integrity and vascularity (Fig. 6.2). This unit must be strongly armed with sutures, re-tensioned, and fixed back to the bone. Reattachment to the bone is performed anteriorly and inferiorly if the tibial insertion is lax or posteriorly and superiorly in case of femoral insertion laxity. The bone around the isometric point is “roughed-up” until good bleeding is achieved. Fixation can be achieved with staples or suture anchors [20, 21]. As in the acute MCL repair, care must be taken to preserve the isometricity, mostly when a proximal en masse elevation is performed, in order to reduce the risk of postoperative stiffness.

A curvilinear incision is placed from the medial femoral epicondyle to the pes anserinus. The sartorius and gracilis tendons are retracted medially. The semitendinosus is harvested, preserving the tibial attachment. The proximal end of the tendon is armed with a n°2 nonabsorbable suture. A 1.6 mm K wire is placed on the posterosuperior border of the medial femoral epicondyle. The semitendinosus tendon is looped around the wire, and isometricity (<2 mm migration) is tested through a full range of motion. A 6.5 mm cancellous screw and an 18 mm diameter soft tissue washer are placed through a hole. The screw hole is drilled 9 mm (the radius of the washer) proximal to the isometric point. Decortication is performed around the drill hole. After manual tensioning of the graft, the screw is tightened with the knee in 30° of flexion and varus stress (Fig. 6.3). Dissection of the direct head of the semimembranous tendon is performed. The free end of the graft is pulled under the direct head of the semimembranosus tendon and sutured to it at 30° of knee flexion [22].

In Stannard’s modification of Kim’s technique, the free end of the semitendinosus is passed under the direct head of the semimembranosus tendon and sutured to the intact insertion of the semitendinosus itself on the tibia (Fig. 6.4). The graft is tensioned with the knee in approximately 40° of flexion and a slight varus stress [23].

Incision, semitendinosus harvesting, and isometricity evaluation are as described by Kim. A tunnel of the same size of the double-looped tendon is drilled at the isometric point on the femur. The tendon loop is then armed with a baseball suture, passed into the tunnel, and fixed with an interference screw (same diameter as the tunnel or 1 mm bigger according to the bone quality). This is performed with the knee at 10° of flexion and neutral rotation. A tibial tunnel (same size of the graft) is then drilled to the posterior corner of the medial tibial condyle from anterior to posterior. The drill hole is aimed to exit 10 mm below the tibial plateau, posterior and lateral to the semimembranosus insertion. The free end of the graft is passed through the posterior tibial tunnel opening and fixed here with an interference screw (same diameter as the tunnel) to reconstruct the POL (Fig. 6.5). This is tightened at 60° of flexion and neutral rotation [24].

This technique entails a reconstruction of both sMCL and POL, through a single medial incision, with two separate grafts and four different tunnels (Fig. 6.6). Allografts or gracilis and semitendinosus autografts can be used. The anatomy of proximal and distal insertions of both bundles needs to be known (Fig. 6.1). Isometricity is evaluated with K wires for both bundles. Correctly sized tunnels are drilled at the isometric points. The sMCL is tightened at 30° of knee flexion and the POL is tightened at 0°. Fixation is achieved with interference screws [25, 26].