Injured Medial Collateral Ligament Research Articles

Management of Iatrogenic Medial Collateral Ligament Injury in Primary Total Knee Arthroplasty: A Systematic Review.

The medial collateral ligament (MCL) injury is one of the possible complications of primary total knee arthroplasty (TKA), which can lead to coronal-plane instability that requires surgical revision. Injured MCL can result in joint instability and polyethylene wear. Different strategies have been proposed for MCL reconstruction based on the location of the injury. However, there is a lack of clarity regarding the optimal method for handling an iatrogenic MCL injury throughout a TKA. A PRISMA flow diagram was used to guide the systematic literature review. An extensive search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar. Newcastle Ottawa scale checklist was used to assess the methodological quality of the articles. A total of 19 qualitative studies, including non-cadaveric patients with MCL injury during TKA, were identified after analyzing the full text of the articles. All included studies were either retrospective, observational cohort or case series. A total of 486 patients were studied to gather information on the methods used to repair the MCL and their results. Most injuries arose in the tibial attachment, which surgeons mostly realized during the final stages of surgery. Used techniques can be categorized into three main groups: Primary repair, Repair with augmentation, and changing prosthesis characteristics. This systematic review demonstrated that the most popular management of iatrogenic MCL injury was using suture anchors, staples, screws and washers, and more constrained prostheses. The proper method should be decided considering the site of the MCL injury.

The effects of different cell-based therapies at a critical time point during the soft-tissue healing process

Background: Cell-based therapy for soft tissue injuries remains controversial. Adult mesenchymal stem cells (MSCs) are therapeutic candidates given their capacity for self-renewal, immunoprivilege, and differentiation capacity for chondrocyte and tenocyte lineages. Platelet rich plasma (PRP) has been reported to promote collagen synthesis and cell proliferation, influencing the healing of ligaments and cartilage. We hypothesize that allogeneic MSCs and PRP have additive effects on promoting ligament healing in an in-vivo rat medial collateral ligament (MCL) injury model. Methods: MCLs of 20 females Sprague rats were bilaterally transected and treated with either saline (controls) or 1 of 3 treatment groups; (1) allogeneic MSCs (105 cells), (2) PRP and (3) allogeneic MSCs & PRP. In addition, five rats were used for the Sham group (surgery + no ligament injury). Rats were sacrificed two weeks post-surgery and the MCLs harvested for histological analysis by hematoxylin and eosin and alcian blue staining. Statistical analysis was performed using Fischer’s exact test with pair-wise comparisons and Bonferroni multiple comparison correction. Results: Histologically, differences across all injured groups (treatment groups and controls) were observed in cellularity (p < 0.0185), regeneration of collagen fibers (p < 0.0084), vascularity (p = 0.0129), inflammation (p = 0.0121) and glycosaminoglycan content (p = 0.0085). From pair-wise comparisons, only the combination allogeneic MSCs & PRP group differed significantly from controls in increased cellularity (p = 9.04 x 10-4) and regeneration of collagen fibers (p = 6.58x10-4). In addition, the PRP group showed significant increase in glycosaminoglycan (p = 0.006) content when compared to the allogeneic MSCs group. Conclusion: The addition of allogeneic MSCs and PRP to an injured MCL show a significant histological increase in degree of cellularity, vascularity and the regeneration of collagen fibers when compared to controls. These data support a possible additive effect of combining allogeneic MSCs and PRP therapy to increase important repair factors during the proliferation/repair phase of post ligament injury. This preliminary study demonstrates that additional functional and biomechanical studies are warranted to determine the role that inflammatory responses versus tissue regeneration are contributing to this mechanism.

Influences of Tumor Necrosis Factor-α on Lysyl Oxidases and Matrix Metalloproteinases of Injured Anterior Cruciate Ligament and Medial Collateral Ligament Fibroblasts.

The anterior cruciate ligament (ACL) fails to heal after injury, even after a primary surgical attempt. In contrast, the medial collateral ligament (MCL) can heal relatively well and restore the full joint function. The difference in intrinsic properties of these ligament cells can be due to their different responses to their local factors. TNF-α is considered to be an important chemical mediator in the wound healing of the ligaments. However, TNF-α-induced expression of lysyl oxidases (LOXs) and matrix metalloproteinases (MMPs) after injury is poorly understood. In this study, we use equi-biaxial stretch chamber to realize 12% stretch, which could mimic the injury to the ACL and MCL fibroblasts in vitro, and aim to determine the intrinsic differences between injured ACL and MCL by characterizing the differential expressions of LOXs and MMPs in response to TNF-α. The methods included Semiquantitative PCR, quantitative real-time PCR, Western blot, and zymography. We found that the mRNAs of LOXs had temporal increases in injured ACL and MCL. Moreover, the increases were higher in injured MCL than those in injured ACL (up to 1.77 ± 0.13-fold in LOX, 1.73 ± 0.21-fold in LOXL-1, 2.23 ± 0.27-fold in LOXL-2, 1.95 ± 0.11-fold in LOXL-3, 1.97 ± 0.28-fold in LOXL-4). On the other hand, the expressions of MMPs in injured ACL were much more prominent than those in injured MCL fibroblasts (up to 2.63 ± 0.20-fold in MMP-1, 3.73 ± 0.18-fold MMP-2, 1.58 ± 0.11-fold MMP-3, 4.23 ± 0.31-fold MMP-12). Similar results were observed at the protein level. The differential expression of LOXs and MMPs between the injured ACL and MCL fibroblasts in this study may help explain the healing abilities of the two different ligaments.

Sonographic Examination of Knee Ligaments.

Sonographic Examination of Knee Ligaments.

Low-Magnitude, High-Frequency Vibration Fails to Accelerate Ligament Healing but Stimulates Collagen Synthesis in the Achilles Tendon.

Background:Low-magnitude, high-frequency vibration accelerates fracture and wound healing and prevents disuse atrophy in musculoskeletal tissues.Purpose:To investigate the role of low-magnitude, high-frequency vibration as a treatment to accelerate healing of an acute ligament injury and to examine gene expression in the intact Achilles tendon of the injured limb after low-magnitude, high-frequency vibration.Study Design:Controlled laboratory study.Methods:Complete surgical transection of the medial collateral ligament (MCL) was performed in 32 Sprague-Dawley rats, divided into control and low-magnitude, high-frequency vibration groups. Low-magnitude, high-frequency vibration started on postoperative day 2, and rats received vibration for 30 minutes a day for 12 days. All rats were sacrificed 2 weeks after the operation, and their intact and injured MCLs were biomechanically tested or used for histological analysis. Intact Achilles tendons from the injured limb were evaluated for differences in gene expression.Results:Mechanical testing revealed no differences in the ultimate tensile load or the structural stiffness between the control and vibration groups for either the injured or intact MCL. Vibration exposure increased gene expression of collagen 1 alpha (3-fold), interleukin 6 (7-fold), cyclooxygenase 2 (5-fold), and bone morphogenetic protein 12 (4-fold) in the intact Achilles tendon when compared with control tendons (P < .05).Conclusion:While no differences were observed in the mechanical or histological properties of the fully transected MCL after low-magnitude, high-frequency vibration treatment, significant enhancements in gene expression were observed in the intact Achilles tendon. These included collagen, several inflammatory cytokines, and growth factors critical for tendons.Clinical Relevance:As low-magnitude, high-frequency vibration had no negative effects on ligament healing, vibration therapy may be a useful tool to accelerate healing of other tissues (bone) in multitrauma injuries without inhibiting ligament healing. Additionally, the enhanced gene expression in response to low-magnitude, high-frequency vibration in the intact Achilles tendon suggests the need to further study its potential to accelerate tendon healing in partial injury or repair models.

TGF-beta1 induces the different expressions of lysyl oxidases and matrix metalloproteinases in anterior cruciate ligament and medial collateral ligament fibroblasts after mechanical injury

The anterior cruciate ligament (ACL) is known to have a poor self-healing ability. In contrast, the medial collateral ligament (MCL) can heal relatively well and restore the joint function. Transforming growth factor-beta1 (TGF-β1) is considered to be an important chemical mediator in the wound healing of the ligaments. While the role of TGF-β1-induced expressions of the lysyl oxidases (LOXs) and matrix metalloproteinases (MMPs), which respectively facilitate the extracellular matrix (ECM) repair and degradation, is poorly understood. In this study, we used equibiaxial stretch chamber to mimic mechanical injury of ACL and MCL fibroblasts, and aimed to determine the intrinsic differences between ACL and MCL by characterizing the differential expressions of LOXs and MMPs in response to TGF-β1 after mechanical injury. By using semi-quantitative PCR, quantitative real-time PCR, western blot and zymography, we found TGF-β1 induced injured MCL to express more LOXs than injured ACL (up to 1.85-fold in LOX, 2.21-fold in LOXL-1, 1.71-fold in LOXL-2, 2.52-fold in LOXL-3 and 3.32-fold in LOXL-4). Meanwhile, TGF-β1 induced injured ACL to express more MMPs than injured MCL fibroblasts (up to 2.33-fold in MMP-1, 2.45-fold in MMP-2, 1.89-fold in MMP-3 and 1.50-fold in MMP-12). The further protein results were coincident with the gene expressions above. The different expressions of LOXs and MMPs inferred the intrinsic differences between ACL and MCL, and the intrinsic differences could help to explain their differential healing abilities.

Interleukin-1 beta influences on lysyl oxidases and matrix metalloproteinases profile of injured anterior cruciate ligament and medial collateral ligament fibroblasts

The anterior cruciate ligament (ACL) is known to have a poor healing ability, especially in comparison with the medial collateral ligament (MCL) which can heal relatively well. Interleukin-1beta (IL-1β) is considered to be an important chemical mediator in the acute inflammatory phase of ligament injury. The role of IL-1β-induced expressions of lysyl oxidases (LOXs) and matrix metalloproteinases (MMPs), which respectively facilitate extracellular matrix (ECM) repair and degradation, is poorly understood. In this study, we aim to determine the intrinsic differences between ACL and MCL by characterising the differential expressions of LOXs and MMPs in response to IL-1β in the injury process. Semi-quantitative polymerase chain reaction (PCR), quantitative real-time PCR, Western blot, and zymography were performed. We detected high expressions of IL-1β-induced LOXs in normal ACL and MCL. Then, we found IL-1β induced injured MCL to express more LOXs than injured ACL (up to 2.85-fold in LOX, 2.58-fold in LOXL-1, 1.89-fold in LOXL-2, 2.46-fold in LOXL-3 and 2.18-fold in LOXL-4). Meanwhile, we found IL-1β induced injured ACL to express more MMPs than injured MCL (up to 1.72-fold in MMP-1, 1.95-fold in MMP-2, 2.05-fold in MMP-3 and 2.3-fold in MMP-12). The further protein results coincided with gene expressions above. Lower expressions of LOXs and higher expressions of MMPs might help to explain the poor healing ability of ACL.

α-Smooth muscle actin and TGF-β receptor I expression in the healing rabbit medial collateral and anterior cruciate ligaments

The aim of our study was to advance the knowledge about the biological differences in the healing of the anterior cruciate ligament (ACL) versus the medial collateral ligament (MCL). We quantified α-smooth muscle actin (α-SMA) expression and TGF-β receptor I (TGF-βRI) expression in experimentally injured rabbit ligaments (from day 3 to 12 weeks post-injury). Myofibroblasts (α-SMA positive cells) were identified as early as the third day post-injury in MCL and their density increased steadily up to day 21. Myofibroblasts were also detected in injured ACL but their density remained very low at all time points. The percentage of positive TGF-βRI area significantly increased in both injured ligaments compared to controls, with a peak expression at day 21; however, it remained constantly lower in ACL compared to MCL. A significant correlation was found between the percentage of TGF-βRI positive cells and the percentage of α-SMA expression only in injured MCL. These results provide evidence that myofibroblasts are important players in MCL remodelling after injury. The combined presence of myofibroblasts and TGF-βRI in the first 3 weeks post-MCL injury may partially explain the difference in the MCL and ACL healing process.

Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing

Controlled laboratory study. To investigate the effects of instrument-assisted cross-fiber massage (IACFM) on tissue-level healing of knee medial collateral ligament (MCL) injuries. Ligament injuries are common and significant clinical problems for which there are few established interventions. IACFM represents an intervention that may mediate tissue-level healing following ligament injury. Bilateral knee MCL injuries were created in 51 rodents, while 7 rodents were maintained as ligament-intact, control animals. IACFM was commenced 1 week following injury and introduced 3 sessions per week for 1 minute per session. IACFM was introduced unilaterally (IACFM-treated), with the contralateral, injured MCL serving as an internal control (nontreated). Thirty-one injured animals received 9 ACFM treatments, while the remaining 20 injured animals received 30 treatments. Ligament biomechanical properties and morphology were assessed at either 4 or 12 weeks postinjury. IACFM-treated ligaments were 43.1% stronger (P<.05), 39.7% stiffer (P<.01), and could absorb 57.1% more energy before failure (P<.05) than contralateral, injured, nontreated ligaments at 4 weeks postinjury. On histological and scanning electron microscopy assessment, IACFM-treated ligaments appeared to have improved collagen fiber bundle formation and orientation within the scar region than nontreated ligaments. There were minimal differences between IACFM-treated and contralateral, nontreated ligaments at 12 weeks postinjury, although IACFM-treated ligaments were 15.4% stiffer (P<.05). IACFM-accelerated ligament healing, possibly via favorable effects on collagen formation and organization, but had minimal effect on the final outcome of healing. These findings are clinically interesting, as there are few established interventions for ligament injuries, and IACFM is a simple and practical therapy technique. J Orthop Sports Phys Ther 2009;39(7):506-514, Epub 24 February 2009. doi:10.2519/jospt.2009.2997.

Expression of MMPs and TIMPs Family in Human ACL and MCL Fibroblasts

The human ACL (anterior cruciate ligament) is susceptible to injury but has poor healing response, whereas an injured MCL (medial collateral ligament) can be repaired relatively well. Since MMPs (matrix metalloproteases) and TIMPs (tissue inhibitor of metalloproteases) are involved in this tissue remodeling process, investigation of different response of MMPs and TIMPs family in ACL and MCL fibroblasts might lead to understanding the differential matrix remodeling process as well as their different healing ability. The first step would be determination of whether these tissue remodeling effectors are present in ligaments. In this study, we designed primers for real-time RT-PCR and determined the expression of MMPs and TIMPs family in ACL and MCL fibroblasts with synovium as a positive control. Semiquantitative RT-PCR revealed that multiple MMPs and TIMPs expressed in human ACL and MCL fibroblasts except MMP-8, 10, 12, 13, 15, 16, 20, and 26. MMP-7 was present in MCL but not in ACL fibroblast. Quantitative real-time RT-PCR showed that mRNA levels of MMP-1, 2, 14, 17, 23A, and 23B and TIMP-4 are significantly higher in MCL than in ACL fibroblasts. However, MMP-3 is higher in ACL than in MCL fibroblasts. We conclude that numerous MMPs and TIMPs family members that are differentially expressed in ACL and MCL might be involved in the differential matrix remodeling process as well as the differential healing ability of ACL and MCL.

Neuropeptides regulate expression of matrix molecule, growth factor and inflammatory mediator mRNA in explants of normal and healing medial collateral ligament

Denervation degrades normal ligament properties and impairs ligament healing. This suggests that secreted neuromediators, such as neuropeptides, could be modulating cell metabolism in ligament and scar tissue. To test this hypothesis we investigated the effect of exogenous substance P (SP), neuropeptide Y (NPY) or calcitonin gene-related peptide (CGRP) on the mRNA levels for proteins associated with inflammation, angiogenesis, and matrix production in tissue-cultured specimens of normal and injured medial collateral ligament. SP and NPY induced increased mRNA levels for several inflammatory mediators in the 2-week post-injury specimens. All three neuropeptides induced decreases in mRNA levels for healing-associated growth factors and matrix molecules, including basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and collagen types I and III. The results indicate that neuropeptides strongly influence the metabolic activity of cells in healing ligament, particularly at early time points after injury.

Vanadate ingestion enhances the organization and collagen fibril diameters of rat healing medical collateral ligaments

Although an injured medial collateral ligament (MCL) will naturally heal, the quality of healing tissue is inferior to the uninjured MCL tissue. Previous studies have shown promising results of sodium orthovanadate (vanadate) in enhancing the quality of rat skin wounds. This study therefore investigated whether vanadate enhances the quality of the rat healing MCL in terms of the collagen fibril organization and diameter. Six mature male Sprague-Dawley rats, with weight ranges of 475-505 g and ages of 25 weeks, were used in this study. Three rats in the experimental group received vanadate (0.2 mg/ml) in their saline drinking water (150 mM NaCl), whereas three rats in the control group were only given saline water. Three weeks after transection, the rat MCLs were harvested for hematoxylin and eosin (H&E) staining and transmission electron microscopy. It was found that vanadate promoted organization of collagen fibrils and significantly increased the diameters of collagen fibrils by 14% in healing MCL (P<0.001). These results indicate that application of vanadate may be a promising tissue engineering approach to enhance the quality of healing tissues such as injured MCLs.

The use of porcine small intestinal submucosa to enhance the healing of the medial collateral ligament––a functional tissue engineering study in rabbits

Introduction: Small intestinal submucosa (SIS) from porcine has been successfully used as a collagen scaffold for the repair of various tissues, including those of the human vascular, urogenital, and musculoskeletal systems. The objective of this study was to evaluate whether SIS can be used to enhance the healing process of a medial collateral ligament (MCL) with a gap injury in a rabbit model. Methods: A 6 mm wide gap was surgically created in the right MCL of 20 skeletally mature, female New Zealand White rabbits. In 10 rabbits, a strip of SIS was sutured onto the two ends of the MCL, while for the other 10 animals their injured MCL remained untreated and served as a non-treated group. The left MCL of all animals was exposed and undermined serving as the sham-operated side. At 12 weeks post-healing, eight hind limbs from each group were used for mechanical testing. The cross-sectional areas (CSA) of the MCLs were measured. The femur–MCL–tibia complex (FMTC) was tensile tested to failure. The load–elongation curves representing the structural properties of the FMTC and the stress–strain curves representing the mechanical properties of the healing MCL were obtained. The remaining two animals from each group were prepared for histological evaluation. Results: The CSA between the SIS-treated and non-treated groups were not significantly different ( p>0.05). Both treatment groups appeared to increase by nearly 40% compared to the sham-operated side, although statistical significance was not found for the non-treated group ( p>0.05). The stiffness of the FMTC from the SIS-treated group was 56% higher than the non-treated group (45.7 ± 13.3 N/mm vs. 29.2 ± 9.2 N/mm, respectively, p<0.05) and the ultimate load also nearly doubled (117.434.5 N vs. 66.4 ± 31.4 N, respectively, p<0.05). These values were lower compared to the sham-operated side (89.7 ± 15.3 N/mm and 332.0 ± 50.8 N, respectively). The tangent modulus of the healing MCL (279.7 ± 132.1 MPa vs. 149.0 ± 76.5 MPa, respectively) and stress at failure (15.7 ± 4.1 MPa vs. 10.2 ± 3.9 MPa, respectively) both increased by more than 50% with SIS treatment ( p<0.05). Yet, each remained lower compared to the sham-operated side (936.3 ± 283.6 MPa and 75.6 ± 14.2 MPa, respectively). Blinded histological comparisons between the SIS-treated MCL and the non-treated control demonstrated qualitatively that the SIS treated group had increased cellularity, greater collagen density, and improved collagen fiber alignment. Conclusion: Healing of a gap MCL injury was significantly enhanced with SIS. The improved mechanical properties and histological appearance of the MCL suggest that SIS treatment improves the quality of tissue and renders the possibility for future studies investigating functional tissue engineering of healing ligaments.

Adaptation of post-traumatic angiogenesis in the rabbit knee by apposition of torn ligament ends.

Apposition of torn ligament ends has been shown to have a beneficial effect on healing of the medial collateral ligament; however, the mechanism underlying this improved recovery is unclear. Excessive post-traumatic angiogenesis, an inherent component of soft-tissue regeneration, may be functionally detrimental in relatively hypovascular tissues such as ligaments. The present study therefore examined the relationship between contact of transected ligament ends and vascular remodeling. Female New Zealand White rabbits were subjected to a gap injury, Z-plasty apposition, or sham operation to the midsubstance of the medial collateral ligament. Six weeks after treatment, the volume of vessels supplying the healing zone of the medial collateral ligament, as well as the ipsilateral lateral collateral ligament, posterior cruciate ligament. menisci, and medial capsule, was quantified by carmine red vascular casting. The volume of vessels supplying the neoligamentous scar formed by gap injury to the medial collateral ligament was found to be twice that of ligaments that had undergone the sham operation, and lateral collateral ligament and meniscal vascularity was also augmented in the injured joint. The medial collateral ligaments that underwent Z-plasty apposition exhibited a level of vascularity comparable with that of the control ligaments that had undergone the sham procedure, whereas meniscal and lateral collateral ligament vascularities remained elevated in this group. Capsular and posterior cruciate ligament vascularities were unaffected by gap injury or Z-plasty to the ipsilateral medial collateral ligament. These findings indicate that injury to the medial collateral ligament not only stimulates angiogenesis in the healing ligament, but other ipsilateral soft tissues also undergo vascular remodeling. Furthermore, apposition of an injured medial collateral ligament modifies these pro-angiogenic events, and this may partly explain why contact of torn ligament ends is beneficial for post-traumatic recovery of an injured joint.

Pregnancy affects cellular activity, but not tissue mechanical properties, in the healing rabbit medial collateral ligament.

Recently, evidence has been accumulating that ligament and joint laxity is altered in women and rabbits during pregnancy. Furthermore, many female adolescents injure ligaments through participation in athletics and other activities. Therefore, to determine whether pregnancy has different effects on the injured and uninjured medial collateral ligament of the rabbit knee, we investigated cellular changes (mRNA levels) and alterations in tissue properties (biomechanics) accompanying pregnancy in animals with the medial collateral ligament injured during adolescence and bred for their primigravid pregnancy as young adults. Assessment of mRNA levels for matrix molecules, matrix metalloproteinases and tissue inhibitor of metalloproteinase-1, growth factors and sex hormone receptors, inflammatory cytokines, inducible nitric oxide synthase, and cyclooxygenase-2 by semiquantitative reverse transcription-polymerase chain reaction revealed that pregnancy had different impacts on scar and uninjured tissue for six of 15 genes assessed. A pregnancy-associated increase in laxity of the medial collateral ligament was observed for rabbits in the uninjured primigravida group; however, no increase was observed for injured rabbits during pregnancy. The injured ligament was already significantly more lax than the normal counterpart, and pregnancy did not lead to additional laxity or prevent the normal decline in laxity as the scar matured in nonpregnant animals. These results indicate that the impact of pregnancy on laxity and cell activity of the medial collateral ligament is dependent on whether the ligament is uninjured or injured. Pregnancy had no significant effect on structural (stiffness and failure load), material (stress at failure and Young's modulus), or viscoelastic (cyclic and static relaxation) properties of tissue from uninjured or injured medial collateral ligament. Therefore, the properties of the healing ligament were not adversely affected during pregnancy in this experimental model. However, it remains to be determined if these results with an injured medial collateral ligament can be extrapolated to the injured anterior cruciate ligament.