medial collateral ligament injuries of the knee ligament... · medial collateral ligament...

Medial Collateral Ligament Injuries of the Knee

Dr. (Prof.) Anil Arora

MS (Ortho) DNB (Ortho) Dip SIROT (USA)

FAPOA (Korea), FIGOF (Germany), FJOA (Japan)

Commonwealth Fellow Joint Replacement

(Royal National Orthopaedic Hospital, London, UK)

Senior Knee and Hip Replacement Surgeon

Associate Director

Department of Orthopaedics and Joint Replacement

Max Superspeciality Hospital, Patparganj, Delhi (India)

E-mail : anilarora@delhiorthojournal.com

12.2mm

12.6mm

61.2mm

3.2mm

Surgically relevant Anatomy

Relevant Anatomy - Attachment

Femoral – oval

3 mm proximal

and 5 mm posterior

to the medial epicondyle

Tibial –

• Proximal tibial attachment

12.2 mm distal to the joint

• Distal tibial is broad

61.2 mm distal to the tibial joint line;

4

Physical Exam - General

Inspection

Palpation

Range of motion

Strength testing

Special tests

MCL Exam

• Valgus force

• > 5 mm difference

significant

• Flex. 300 – Isolated MCL

• Extension

– Assoc. POL, ACL, PCL

Examination

Increased MJO at 30 of flexion but not at 0 The posterior oblique ligament is

most likely still intact

Medial knee structures are completely

ruptured, there will be no definitive

end point and the anterior cruciate ligament

may be providing a secondary restraint

to the valgus stress Verify this observation with the

Lachman, anterior drawer, and pivot

shif tests and assess the integrity of

the anterior cruciate ligament

Complete injury to the medial structures will

cause increased external rotation at Positive dial test

both 30 and 90 of knee flexion,

Increased MJO at 0 & 30 degree of

knee flexion The MCL and POL both are torn

Grades of tear

3-5 mm

laxity

6-10 mm

laxity

>10 mm

laxity

Stress Radiograph

Isolated injury of superficial medial collateral ligament

Complete medial knee injury (superficial medial collateral ligament,posterior oblique ligament, and deep medial collateral ligament)

Increases in medial joint gapping of 1.7 mm at 0 of knee flexion and 3.2 mm at 20 of knee flexion*

Increases in medial joint gapping of 6.5 mm at 0 of knee flexion and 9.8 mm at 20 of knee flexion*

Why MRI

• Grade and site

• Can show entrapped end of torn ligament into

the joint

• Can show torn distal end lying superficial to

Pes Anserinus, and hence indication for

surgery.

Can we treat Nonoperatively

All grade -I sprains

All grade –II sprains

Some grade –III sprains

What are those grade III tear - Nonoperatively

If the tear is at the proximal attachment and there is no

evidence of other ligamentous damage

Elderly patients who do not expect to return to

vigorous activities or to place great demands

Do I need to put a plaster

No

Brace is optimum

Crutch walking is permitted with toe-touch weight

bearing soon

Full extension is obtained by 6 weeks

Treatment with early Protected ROM Exercises

and Progressive Strengthening >>>>> Excellent

Results and

a high rate of Return to Sports

Reider B, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional

rehabilitation. A five-year follow-up study. Am J Sports Med. 1994;22(4):470–477.

Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial

collateral ligament of the knee in intercollegiate football players. Clin Orthop. 1990;256:174–177.

Pforringer W, Beck N, Smasal V. Conservative therapy of ruptures of the medial collateral ligament of the knee.

Results of a comparative follow-up study. Sportverletz Sportschaden.1993;7(1):3–7.

Petermann J, von Garrel T, Gotzen L. Non-operative treatment of acute medial collateral ligament lesions of the

knee joint. Knee Surg Sports Traumatol Arthrosc. 1993;1(2):93–96.

Success of non-operative treatment

of complete tears of the

medial knee structures relies on an

Intact Anterior Cruciate Ligament

OPERATIVE

Surgical indications

• Presence of intraarticular ligamentous entrapment

• A large bony avulsion

• Associated tibial plateau fracture

• Complete tibial side avulsion

• Presence of valgus instability in 0 degrees of flexion in an

underlying valgus knee alignment

Injury over the whole length

of the superficial layer,

or a complete injury of

both the superficial and deep MCL from the tibia

• Wilson TC, Satterfield WH, Johnson DL. Medial collateral ligament "tibial" injuries: indication for

acute repair. Orthopedics. 2004;27(4):389–393.

• Nakamura N, et al. Acute grade III medial collateral ligament injury of the knee associated with

anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a

treatment regimen. Am J Sports Med. 2003;31(2):261–267.

Operative techniques for fresh injuries

• Direct repair of the superficial MCL & POL

• Primary repair with augmentation

• Advancement of the tibial insertion of the Superficial MCL

• Pes anserinus transfer

• Advancement of the superficial MCL with pes anserinus transfer

Tip 1 : Anchor ligament at Isometric point

Origin –oval and,

on the average, 3 mm proximal and 5

mm posterior to the medial

epicondyle

Insertion – proximal tibial

attachment is located an average of

12.2 mm distal to the tibial joint

• The distal tibial is broad and is 61.2

mm distal to the tibial joint line;

Suture anchor repair

Internal fixation should not be used in areas where normal

gliding of the ligament is required during flexion and

extension.

Neither the screw with toothed washer nor the staple should

be overly tightened or countersunk

Approximating sutures apposing the dissected torn edges of

the ligament should be reinforced with tension sutures of non

absorbable material.

Surgical tips

Surgical tips

The superficial medial collateral ligament is tightened at

30 of knee flexion

The posterior oblique ligament is tightened at

0 degree of knee flexion

Rehabilitation program after Repair

The initial range-of-motion exercises (2 weeks)

Prevent adhesion formation;

Extension is allowed to 0

Avoid both hyperextension and flexion past 90

After the initial two weeks

Knee flexion to a full range of motion

No resistive or repetitive hamstring exercises for

approximately four months after the reconstruction

After the initial six weeks of protected weight-bearing

Closed kinetic- chain exercises

Rehabilitation program after Repair

Once full weight-bearing is permitted at the seven-week

Special attention must be paid to the restoration of

normal gait mechanics

Must observe the gait pattern closely

Ensure that the patient is not employing a quadriceps-

avoidance pattern with a hyperextension thrust at the

knee joint during stance phase.

It is also critical that the patient avoid

Posting the foot of the surgically treated extremity lateral

to the base of support in stance in an attempt to unload

the joint

Illustration-1

• Manoj 24/M

• RTA

• ACL, MCL ruptured

• Depressed # Lat. Tibia

MRI

Treatment

• Tibial fixation of MCL

• Repair of PMC, distal most limb of SMCL

• Elevation of depressed tibial condyle

• Filling of void with bone graft

• Across the knee Ex. Fix

Surgical scar

Postop 3 months

Postop 3 months

Postop 3 months

12 months follow up MRINicely reconstituted MCL

Illustration-2

• Vimal, 31/M

• RTA

• Medial opening on valgus

• MCL avulsion femoral side

MRI

MRI

Treatment

• Anatomical restoration of MCL

• Fixation by staple

• Early mobilization

• Protected weight bearing

• QUAD. Exercises

8 weeks postop

12 weeks postop

12 weeks postop

12 weeks postop

Illustration-3

• Sunil,38/M

• RTA

• Medial joint pain

• Give-way

• Apprehension of fall

• Difficult to walk

Postop X-ray

6 Wks

12 Wks

A square or rectangular pattern is used in the manner of

a mattress suture to secure the tension sutures.

Careful alignment of the tension sutures along the

course of the ligament fibers is necessary

Tension sutures can be tested for functional placement

and isometry during flexion and extension before being

tied definitively.

Surgical tips

Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L.Force measurements on the posterior oblique ligament and superficial medialcollateral ligament proximal and distal divisions to applied loads.

Am J Sports Med. 2009;37:140-8.

Aim of an operative repair or reconstruction of the superficial

medial collateral ligament is to restore the distinct functions of

both divisions by reattaching the two tibial attachments in an

attempt to reproduce the overall function Of the superficial

medial collateral ligament construct.

Goal-oriented rehabilitation program treated conservatively

Initial treatment

• Apply ice with compressive wrap for 20 minutes and repeat every 3-4 hours for the first 24-48 hours.

• Apply minimally restrictive lateral hinge brace (grade II or III injuries).

• Dispense crutches; allow weight bearing as tolerated.

Subsequent treatment

• Begin active range-of-motion exercises in cold whirlpool at least twice daily.

• Begin straight-leg raises and electrical muscle stimulation (if available).

• Maintain general conditioning with upper body ergometer or swimming.

Goal-oriented rehabilitation program treated conservatively

• Goal one: Walking unassisted without a limp

• Goal two: 90 degrees of knee flexion

• Goal Three: Full knee motion

• Goal four: Complete entire running program in one session

Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996;21(2):147–156.

Postop 2 months

Postop 2 months

Postop 3 months

Postop 3 months

Postop 3 months

12 weeks postop

12 weeks postop

Thanks