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MCL Injuries of the Knee

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Title: MCL Injuries of the Knee


1
MCL Injuries of the Knee
  • Kristopher Aalderink, MD
  • Orthopaedic Surgery, Sports Fellow
  • August 14, 2008

2
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3
Presentation Objectives
  • Anatomy Function of the MCL
  • Biomechanics of MCL
  • Physical Exam Techniques
  • Diagnostic Studies
  • Types of Injuries
  • Treatment Options
  • Nonsurgical
  • Surgical

4
Medial Collateral Ligament (MCL)
  • One of the most commonly injured ligaments about
    the knee.
  • Common in sports involving valgus knee loading
    (football, ice hockey, skiing)

5
Anatomy of the MCL
  • Composed of both static dynamic parts.
  • Static components
  • Superficial MCL (primary stabilizer)
  • Deep MCL, a thickening of the medial capsule
  • Posterior oblique ligament
  • Dynamic components semimembranosis, vastus
    medialis, and pes anserinus.

6
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7
Anatomy cont
  • Three-layer concept described by Warren
    Marshall
  • Layer I
  • Deep fascia, Sartorius
  • Layer II
  • Superficial MCL
  • Layer III
  • Deep MCL
  • Posterior oblique ligament- confluence of layers
    2/3

8
MCL Function
  • Main function is to resist valgus and external
    rotation forces of the tibia in relation to the
    femur.
  • Primary stabilizer to valgus force.
  • Secondary stabilizer to anterior translation.

9
Basic Biomechanics
  • Anterior parallel fibers in constant tension
    throughout flexion, whereas posterior fibers were
    oblique and slackened in flexion .
  • MCL is tight in external rotation.
  • With knee flexion gt 90 degrees,
    the tibia internally rotates,
    relaxing the anterior
    fibers.
  • MCL has 1.5cm of excursion
    during knee
    flexion/extension.

10
Biomechanics
  • The ultimate strength of the human MCL has been
    shown to be approximately equal to that of the
    anterior cruciate ligament (ACL).
  • The location of maximum strain of the MCL from
    cadaver studies was found to be near the femoral
    insertion with the knee in full extension.
  • In contrast to the ACL, the MCL has shown
    excellent healing capability in both animal and
    clinical studies.

11
History Physical Examination
  • Mechanism of injury and the position of the knee
    when it was injured.
  • Vast majority from direct blow to lateral
    leg/thigh
  • Hughston and colleagues found that 76 of
    athletes with grade III injuries could walk into
    the office unaided by external support.

12
Physical Examination cont
  • Patellar tenderness, apprehension, and medial
    retinacular tenderness are sought because
    patellar dislocation is associated with valgus
    injuries.
  • Hunter and colleagues found a 9 to 21 incidence
    of damage to the extensor mechanism (vastus
    medialis tearing) with medial ligament injury.

13
MCL Physical Examination
  • The gold standard for medial instability is a
    valgus stress test performed at 30 degrees of
    knee flexion.
  • If medial opening at 0 degrees, suspect a
    combined ligamentous injury.
  • Always compare to
    contralateral limb!




14
MCL
  • Concomitant ligamentous injuries
  • 20 of grade I
  • 52 of grade II
  • 78 of grade III
  • ACL most commonly associated combined ligament
    tear

15
MCL Physical Examination
  • Proximal MCL tears at the femoral insertion are
    more common than at the distal tibial insertion.
  • In general, femoral side injuries tend to heal
    better than tibial side or midsubstance injuries.

16
Diagnostic Studies
  • A-P, Lateral, Merchant (if indicated)
  • Stress views
  • MRI r/o associated
    injuries

17
Diagnostic Studies
Pellegrini-Stieda lesion Chronic MCL injury
characterized by a bony avulsion with
calcification of femoral insertion of MCL
Physeal injury
18
MCL Grading System(Hughston)
Grade Description
I involves a few fibers resulting in localized tenderness but no instability
II disruption of more fibers, with more generalized tenderness but still no instability
III complete disruption of the ligament, with resultant instability
1 3-5 mm
2 6-10 mm
3 gt 10 mm
Laxity determined with knee in 30 degrees of
flexion
19
MCL Grading(Fetto Marsh)
Grade Description
1 Stable to valgus stress at 0 30 degrees of knee flexion
2 Laxity at 30 degrees of flexion, stable at 0.
3 Valgus laxity at both 0 30 degrees flexion
20
Treatment of Isolated MCL Injury
  • Stable to valgus stress in extension
  • Non-Surgical Treatment
  • Crutches until pain subsides, WBAT
  • Quad isometrics and ROM
  • Hinged-knee brace
  • Edema Control - Ice, Compression, Massage
  • /- NSAIDs

21
MCL Surgical Indications
Acute Repair Presence of intraarticular ligamentous entrapment A large bony avulsion Associated tibial plateau fracture MRI finding of complete tibial side avulsion in athletes Presence of AMRI Presence of valgus instability in 0 degrees of flexion w/ valgus knee alignment
Delayed repair Combined with anterior cruciate or other ligament reconstruction if the examination under anesthesia shows valgus laxity in 0 degrees of flexion
Augmentation Combined with any repair if local tissue is deficient
Reconstruction Symptomatic chronic valgus laxity
Distal Femoral Osteotomy Chronic valgus laxity with valgus bony alignment
22
Entrapped MCL
23
Acute Repair Surgical Technique(within 7-10
days)
  • Femoral avulsion - ligament can be approximated
    using suture anchors, staples, or a screw and
    washer.
  • most problems with postoperative motion because
    of capsular adhesions and dysfunction of the
    extensor mechanism
  • Tibial avulsion (superficial and deep components)
    repair can be performed using either suture
    anchors or staples, restore tension
  • Mid-substance may require augmentation or
    allograft reconstruction.

24
Chronic MCL Repair(gt 3 months)
  • Focus mainly on reconstruction of the superficial
    MCL
  • Numerous options quadriceps tendon autograft,
    hamstring autograft, hamstring allograft, or
    Achilles allograft
  • Associated valgus deformity of the knee
  • distal femur varus-producing osteotomy

25
Combined ACL MCL Injury
  • Problems with loss of motion with early
    reconstruction of both the ACL and MCL
  • Many authors recommend ACL reconstruction after a
    period of rehabilitation to allow the MCL to heal
  • Delay until full ROM, adequate strength,
    resolution of knee effusion
  • Residual valgus laxity post ACL reconstruction ?
    reconstruct MCL

26
References
  • DeLee DeLee and Drez's Orthopaedic Sports
    Medicine, 2nd ed.
  • Derscheid et al, Medial collateral ligament
    injuries in football. Nonoperative management of
    grade I and grade II sprains Am J Sports Med.
    1981 Nov-Dec 9(6) 365-8.
  • Hughston JC, Barrett GR Acute anteromedial
    rotatory instability. Long-term results of
    surgical repair. J Bone Joint Surg Am 1983 65
    145-153.
  • Hunter SC, Marascalco R, Hughston JC Disruption
    of the vastus medialis obliquus with medial knee
    ligament injuries. Am J Sports Med 1983 11
    427-431.
  • Indelicato, Isolated Medial Collateral Ligament
    Injuries in the Knee, J Am Acad Orthop Surg 1995
    3 9-14.

27
References
  • Iowa Orthopaedic Journal, MCL injuries of the
    knee Current concepts review, Vol. 26, pp 77-90.
  • Master Techniques in Orthopaedic Surgery
    Reconstructive Knee Surgery, LWW2nd ed, 2003.
  • O'Donoghue DH Reconstruction for medial
    instability of the knee. J Bone Joint Surg Am
    1973 55941-954.
  • O'Donoghue DH Treatment of acute ligamentous
    injuries of the knee. Orthop Clin North Am
    1973 4617-645.
  • Shelburne et al, ACL-MCL injury nonoperative
    management of MCL tears with ACL reconstruction.
    A preliminary report. Am J Sports Med
    20283-286, 1992.
  • Sports Medicine, Core Knowledge in Orthopaedics,
    Miller, Sekiya, 2006.

28
  • ??? QUESTIONS ???
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