Medial Collateral Ligament Injury Research Articles

The prevalence of soft tissue injuries in operative Schatzker type IV tibial plateau fractures.

To describe the incidence of soft-tissue injuries in patients with surgically treated Schatzker type IV tibial plateau fractures. All tibial plateau fractures in skeletally mature patients treated operatively between January 2013 and August 2018 were retrospectively reviewed using a clinical medical record system. All fractures were categorized according to the AO/OTA classifications. Twenty-seven patients with Schatzker type IV tibial plateau fractures were further classified based on the Wahlquist classification. Associated soft-tissue injuries, which consisted of cruciate ligament injuries, and meniscal and collateral ligament injuries, were diagnosed through operation notes and magnetic resonance imaging (MRI) data. The categorical variables were tested by the chi-square test or Fisher's exact test. The incidence of lateral meniscus tears and medial meniscus tears was 63% and 44.4% in Schatzker type IV tibial plateau fractures, respectively. Twenty-five (92.6%) patients had sustained anterior cruciate ligament (ACL) injuries, and 19 (70.4%) patients had an incomplete injury of the posterior cruciate ligament (PCL). There were 17 (63%) lateral collateral ligament (LCL) injuries, and 8 (29.6%) medial collateral ligament (MCL) injuries. Using the Wahlquist classification, these fractures were categorized as follows: type A, one patient; type B, six patients; type C, twenty patients. There was no significant difference between the type of fracture and the location of soft tissue injuries. This study found that operative Schatzker type IV tibial plateau fractures represented a high incidence of soft-tissue injuries, especially LCL injuries, ACL injuries, and meniscus tears. Based on our data, we believe that soft-tissue injuries in operative Schatzker type IV tibial plateau fractures deserve more attention.

Linear Discriminant Analysis Successfully Predicts Knee Injury Outcome From Biomechanical Variables

Background: The most commonly damaged structures of the knee are the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and menisci. Given that these injuries present as either isolated or concomitant, it follows that these events are driven by specific mechanics versus coincidence. This study was designed to investigate the multiplanar mechanisms and determine the important biomechanical and demographic factors that contribute to classification of the injury outcome. Hypothesis: Linear discriminant analysis (LDA) would accurately classify each injury type generated by the mechanical impact simulator based on biomechanical input variables (ie, ligament strain and knee kinetics). Study Design: Controlled laboratory study. Methods: In vivo kinetics and kinematics of 42 healthy, athletic participants were measured to determine stratification of injury risk (ie, low, medium, and high) in 3 degrees of knee forces/moments (knee abduction moment, anterior tibial shear, and internal tibial rotation). These stratified kinetic values were input into a cadaveric impact simulator to assess ligamentous strain and knee kinetics during a simulated landing task. Uniaxial and multiaxial load cells and implanted strain sensors were used to collect mechanical data for analysis. LDA was used to determine the ability to classify injury outcome by demographic and biomechanical input variables. Results: From LDA, a 5-factor model (Entropy R2 = 0.26) demonstrated an area under the receiver operating characteristic curve (AUC) for all 5 injury outcomes (ACL, MCL, ACL+MCL, ACL+MCL+meniscus, ACL+meniscus) of 0.74 or higher, with “good” prediction for 4 of 5 injury classifications. A 10-factor model (Entropy R2 = 0.66) improved the AUC to 0.86 or higher, with “excellent” prediction for 5 injury classifications. The 15-factor model (Entropy R2 = 0.85), produced 94.1% accuracy with the AUC 0.98 or higher for all 5 injury classifications. Conclusion: Use of LDA accurately predicted the outcome of knee injury from kinetic data from cadaveric simulations with the use of a mechanical impact simulator at 25° of knee flexion. Thus, with clinically relevant kinetics, it is possible to determine clinical risk of injury and also the likely presentation of singular or concomitant knee injury. Clinical Relevance: LDA demonstrates that injury outcomes are largely characterized by specific mechanics that can distinguish ACL, MCL, and medial meniscal injury. Furthermore, as the mechanics of injury are better understood, improved interventional prehabilitation can be designed to reduce these injuries.

Use of Biologics for Knee Collateral Ligament Injuries. Can We Heal Them Faster?

There is a relative paucity in the orthopaedic literature regarding the use of biologics for collateral ligament injuries. A majority of the existing literature on this topic is preclinical, and only considers the use of biologics in medial collateral ligament injury, with only 2 clinical case reports (level V evidence) that describe the use of platelet rich plasma in human medial collateral ligament injuries. Further, at this time there are no studies, clinical or preclinical, that examine the effects of biologics on fibular collateral ligament injuries. Considering this relative paucity, further research is needed to investigate the utility of biologic agents with respect to collateral ligament injuries. Promising science should not be blindly implemented without clinical trials demonstrating successful, reproducible outcomes.

Multi-Ligament Knee Injuries in Elite Athletes: return to play rates, timing, and complications

Objectives:Historically, combined ligament injuries of the knee have been considered career ending for elite athletes. The objective of this paper was to provide a reference when counseling athletes and medical staffs in regards to outcomes following combined ligament knee injuries in elite athletes.Methods:A retrospective assessment of all elite athletes (professionals or amateurs at a national level) who had sustained a combined ligament knee injury in the period February 2001 to December 2015 was performed. Cases with a minimum of 2 ligaments needing surgery were included (of note, all medial collateral ligament (MCL) injuries were grade 3). The minimum follow up was 2 years. The outcomes recorded were: return to play or not, level of play returned to, time to return to play, and complications. This data was available in 100% of cases.Results:109 procedures were performed in 108 elite athletes. The mean age was 24.3 years old. Sports represented were: soccer (60 athletes), rugby (38 athletes), Judo (3 athletes), gymnastics (3 athletes), basketball (1 athlete), cricket (1 athletes), netball (1 athlete), and skiing (1 athlete). The distribution of injuries, rate of return to play and average return time can be seen in Figure 1. 40 of the 109 (36.7%) knees operated on underwent a minimum of one more surgical procedure during this period. The most common was manipulation under anesthesia (16 out of 109), followed by arthroscopic meniscectomy (9 out of 109). 2 out of 109 knees required revision ligament reconstruction.Conclusion:This study focuses on the ability to return to play, the level of play possible, and how long recovery takes, the factors most important to elite athletes. This study is unique and provides a reference point for future work, as well as being valuable to athletes and their medical and coaching teams.With such a large experience of these challenging injuries the senior author has learned key lessons. The only injuries that must have acute surgery (within first 2-3 weeks) are: those with a vascular lesion (rare in sport); irreducible dislocation (usually ‘button-holed’ medial femoral condyle); PLC structure injuries; and uncontrollable grade 3 PCL. With modern bracing much of the soft tissue envelope will heal- especially MCL tears of all grades and PCL grade 1 and 2. Early surgery, especially when it involves the MCL, has a high chance of stiffness requiring surgical intervention. The majority of injuries can be braced and safely dealt with when acute inflammation has resolved and motion is restored. Some injuries are best treated with staged surgery, specifically when the PLC is involved. Even in experienced hands, these cases often require subsequent procedures. It is critical to educate the patient and the team’s staff about this possibility at the onset of treatment. In addition, while the average return to play times range from 7-25 months, it takes at least 2-3 years to return to peak form due to the proprioceptive deficit sustained with these injuries. While these injuries can be career ending in elite sport, this case series shows that with modern treatment strategies and techniques, good results can be achieved in a high number of cases.Table 1. Injury Number Return to sport Return to same levelAve time taken (months)ACL + MCL3631 (86%)29 (81%)10.2ACL + PLC3933 (85%)26 (67%)12.9ACL + MCL + PLC43215ACL + PCL33212.3PCL + MCL44317.5PCL + PLC109 (90%)9 (90%)14.9MCL + PLC1114Bicruciate + MCL41113Bicruciate + PLC55318.2ACL/PCL/MCL/PLC33222PLC = Posterolateral corner

Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study

Objective A multicenter study to evaluate risk factors for the development of moderate or severe posttraumatic osteoarthritis (PTOA) and to find potential preventions. Methods We conducted a retrospective multicenter study including the terrible triad injury (TTI) patients with surgical treatment from January 2007 to November 2014. Demographics, injury information, and treatment history were obtained retrospectively. According to the Broberg and Morrey criterion, 198 included patients were sorted into two groups: the mild or no PTOA and moderate or severe PTOA. Uni- and multivariate logistic regression analyses were used to identify risk factors for moderate or severe PTOA. Results Moderate or severe PTOA was present in 64 patients (32.3%). Significant risk factors were Mason III radial head fracture (OR 4.049, 95% CI 1.877-8.736, p < 0.001), medial collateral ligament injury (OR 5.120, 95% CI 1.261-20.790, p = 0.022), and heavy use of elbow (OR 2.333, 95% CI 1.060-5.136, p = 0.035). Besides, patients suffered subluxation (p = 0.007) and those with more risk factors had a higher risk to develop moderate or severe PTOA. Conclusions Moderate or severe PTOA was common after the TTI. Patients need to be counseled about avoiding heavy use of the elbow, especially for those with Mason III radial head fractures. Surgeons should be aware of the recurrent instability of the elbow.

The Medial Collateral Ligament in Primary Total Knee Arthroplasty: Anatomy, Biomechanics, and Injury.

Understanding the anatomy and biomechanics of the medial collateral ligament (MCL) is crucial in producing good outcomes after total knee arthroplasty. A solid grasp of the surgical techniques that address the MCL are necessary to ensure good coronal plane ligament balance. Furthermore, intraoperative injury to the MCL in total knee arthroplasty is an uncommon yet serious complication which often goes unrecognized. Loss of the integrity of the MCL can lead to instability, loosening, and accelerated polyethylene wear. There is still controversy regarding the ideal method of treatment of intraoperative MCL injuries with suggested treatment modalities ranging from conservative management to use of varus-valgus constrained implants.

One-Stage Repair of Posterior Oblique Ligament Avulsion Fracture Combined with Medial Collateral Ligament Injury.

ObjectiveTo evaluate the clinical effect of the one‐stage repair of a posterior oblique ligament avulsion fracture combined with a medial collateral ligament injury.MethodsThis study was a retrospective trial. From February 2007 to May 2017, five patients with posterior oblique ligament avulsion fracture combined with medial collateral ligament injury were included in this study. The patients were aged 37–58 years old with a mean of 45.2 years. All patients underwent the primary repair of a posterior oblique ligament avulsion fracture and medial collateral ligament injury. The main observational index included Lysholm score, International Knee Documentation Committee (IKDC) score, Visual Analogue Scale (VAS) score, and range of motion (ROM).ResultsThe results showed that the average time of follow‐up was 53.6 months (range, 20–86 months). When compared to preoperative scores, the preoperative Lysholm score was significantly increased (47.8 ± 5.1 vs 95.0 ± 3.7, P < 0.05), the IKDC score was significantly increased (51.2 ± 5.6 vs 88.6 ± 4.2, P < 0.05), the VAS score was significantly decreased (7.0 ± 0.7 vs 0.4 ± 0.5, P < 0.05), and the ROM was significantly increased (91.6° ± 8.4° vs 129.9° ± 4.4°, P < 0.05).ConclusionOur study found that with the combination of the one‐stage repair of a posterior oblique ligament (POL) avulsion fracture and medial collateral ligament injury, the patient's postoperative function recovered well, their pain was relieved, and their knee joint stability was reliable.

The anterolateral ligament in acute knee trauma: patterns of injury on MR imaging.

To delineate the spectrum of traumatic knee injuries associated with injury of the anterolateral ligament of the knee (ALL). A retrospective review of 200 MRI scans undertaken for acute knee trauma was performed. In each scan, the ALL was scored as normal, sprained or torn. The menisci, ligaments and tendons of each knee were also assessed. The mean age was 27.4years (range, 9-69years), and 71.5% (n= 143) of the patients were male. The anterolateral ligament (ALL) was graded as ruptured in 17 cases (8.5%), sprained in 58 cases (29%), normal in 116 cases (58%) and not visible in 9 cases (4.5%). Of cases with injury of the ALL (n= 75), there was associated injury of the anterior cruciate ligament (ACL) in 61 cases, medial collateral ligament (MCL) in 51 cases, popliteofibular ligament (PFL) in 29 cases, medial meniscus in 29 cases, lateral meniscus in 24 cases, lateral collateral ligament in 9 cases, posterior cruciate ligament in 8 cases, biceps femoris in 5 cases, popliteus tendon in 4 cases and fluid or oedema was seen adjacent to the iliotibial band in 59 cases. No cases of isolated ALL injury were seen. ALL injury is not uncommon in acute knee trauma and is typically associated with significant internal derangement of the knee, especially anterior cruciate ligament rupture, ITB sprain, medial collateral ligament injury, meniscal tears and injury to the popliteofibular ligament.

Analysis of Risk Factors for Ramp Lesions Associated With Anterior Cruciate Ligament Injury

Background: The incidence of meniscocapsular junction tears of the medial meniscus posterior horn, known as ramp lesions, is reported to be 9.3% to 23.9%. However, these lesions are not consistently diagnosed with routine arthroscopic exploration and magnetic resonance imaging (MRI). Purpose: To determine risk factors associated with ramp lesions in anterior cruciate ligament–injured knees. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 275 patients undergoing anterior cruciate ligament reconstruction between June 2011 and March 2019 were included in this study. Exclusion criteria were revisions, fracture histories, and multiple-ligament injuries other than medial collateral ligament injury. Patients were divided into 2 groups, those with and without ramp lesions according to arthroscopic diagnosis. Binary logistic regression was used to analyze risk factors: age, sex, body mass index, time from injury to surgery (<3 or ≥3 months), mechanism of injury (contact/noncontact), Segond fracture, side-to-side laxity, location of bone contusion, medial and lateral tibial/meniscal slope, and mechanical axis angle. Receiver operating characteristic curves and area under the curve were evaluated. A prediction model was developed by multivariable regression with generalized estimating equations. Results: Overall, 95 patients (34.5%) were confirmed as having a ramp lesion. The sensitivity of MRI for ramp lesions was 85.3%, and specificity was 78.3%. Significant risk factors for ramp lesion were as follows: posterior medial tibial plateau bone contusion on MRI (odds ratio [OR], 4.201; 95% CI, 2.081-8.482; P < .001), ≥3 months from injury (OR, 4.818; 95% CI, 2.158-10.757; P < .001), varus knee >3° (OR, 2.339; 95% CI, 1.048-5.217; P = .038), steeper medial tibial slope (OR, 1.289; 95% CI, 1.002-1.66; P = .049) and meniscal slope (OR, 1.464; 95% CI, 1.137-1.884; P = .003), and gradual lateral tibial slope (OR, 0.775; 95% CI, 0.657-0.914; P = .002). The area under the curve for the prediction model developed by logistic regression was 0.779 (sensitivity, 75.8%; specificity, 71.7%; P < .001) for ramp lesions. Conclusion: Care should be taken with patients who have significant risk factors for ramp lesions, including bone contusion at the posterior medial tibial plateau, chronic injury, steeper medial tibial and meniscal slope, gradual lateral tibial slope, and varus knee >3°.

Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players

Background: For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation. Hypothesis: There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players. Study Design: Case-control study; Level of evidence, 3. Methods: Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP. Results: A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone–patellar tendon–bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant. Conclusion: The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

Primary Repair for Injury of Medial Collateral Ligament During Total Knee Arthroplasty

This study, we aim to determine whether intraoperative over-release of MCL that is treated with primary repair can achieve satisfactory clinical results when compared to those who did not have over-release of MCL. At the same time, we seek to look into the difference between two methods of primary repair (anchor suture and staple) in terms of clinical outcomes.Purposes:We determined whether, after TKA, patients with CIA versus patients with CACB demonstrated (1) decreased pain scores (2) greater ambulatory ability postoperatively (3) decreased daily opioid consumption and hospital length of stayMethods:3897 TKAs were performed from year 2003-2014. Sixty-five patients with MCL injury due to over-release during TKA who were repaired with suture anchor or staple (suture anchor: 36 vs. staple: 29) were studied whereas matched group of 65 patients without MCL injury were selected and served as the control group. Subjective feeling of instability and functional score were assessed using Knee Society Score (KSS) and Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC). Objective stability was evaluated through measurement of opening angles in extension and 30° of knee flexion on valgus stress radiographs. The clinical and stability results of repair between the suture anchor and staple were compared.Results:The KSS and WOMAC scores in patients with primary repair of MCL during TKA from 50.6±14.8 to 87.3±8.3 and 65.9±16.3 to 17.7±8.3, respectively. However, there were neither statistical nor clinical significant difference when comparing between the group with primary repair and the control group. Radiographic stability also showed no differences between repair and control groups in extension and 30° of flexion (p= .63 and p= .37). Regarding the subgroups, There were no significant differences between the suture anchor and staple in terms of the stability and clinical outcomesConclusion:Primary repair either with suture anchor or with staple for injury of the MCL in varus gonarthrosis during TKA provides a good stability and clinical outcomes as those of result with no MCL injury.

Posteromedial Ligament Repair of the Knee with Suture Tape Augmentation: A Biomechanical Comparison with Posteromedial Ligament Reconstruction

Aims and Objectives:ACL ruptures combined with injuries of the superficial medial collateral ligament and posterior oblique ligament (= posteromedial ligament complex; PMC) are common. In acute cases with high-grade valgus and rotatory instability, primary repair of the PMC with suture tape augmentation may be a reasonable alternative to standard reconstruction techniques, in order to stabilize the knee and to protect the reconstructed ACL. The aim of the present study was to biomechanically examine the rotational and valgus stability, as well as the influence on ACL strain, following PMC repair with suture tape augmentation in comparison with posteromedial ligament reconstruction using tendon grafts.Materials and Methods:Ten cadaveric knee specimens were tested with the tibia fixed and the femur mobile on an X-Y-table. Each specimen was tested in four different conditions according to the state of the PMC: 1) native, 2) femoral avulsion, 3) repaired with suture tape augmentation, 4) reconstructed with tendon allografts. Valgus instability was tested with 40 N force applied in the lateral direction of the femur and rotational motion was tested with 5 N torque applied to the tibia. An optical 3D motion tracking system captured the valgus angle and the internal and external rotation. Additionally, the strain on the ACL during valgus stress was measured with a DVRT. Each condition was tested in 0°, 15°, 30°, 45° and 60° of knee flexion.Results:Femoral avulsion of the PMC led to a significant increase in valgus instability in all flexion angles and to a significant increase on ACL strain at 30° (Native 1.37 ± 2.33 vs. deficient 7.49 ± 7.00; p<0.001) and 45° (0.88 ± 1.66 vs. 2.82 ± 2.59; p<0.001) knee flexion. Additionally, a significant increase of internal rotation in 0° (p=0.018) and 30° (p=0.005) knee flexion and a significant increase of external rotation in 15° (p<0.001), 30° (p=0.016), 45° (p=0.006) and 60° (p=0.012) knee flexion was seen after dissection of the PMC.PMC repair with suture tape augmentation demonstrated similar valgus and rotational stability compared to intact specimens, with the exception of increased internal rotation at 30° (16.2 ± 6.3° vs. 19.3 ± 6.9°; p=0.005). PMC reconstruction with tendon grafts led to a significantly increased valgus opening at a 45° degree of knee flexion (7.5 ± 2.9° vs. 8.9 ± 2.1°; p=0.048) and significantly increased internal rotation at 30° (16.2 ± 6.3° vs. 20.1 ± 7.3°; p<0.001) compared to the native state. Direct comparison between both surgical techniques showed no significant differences.Conclusion:At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close to native valgus and rotatory stability, as well as native ACL strain for cases of complete PMC avulsion. Posteromedial ligament repair with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in acute cases of combined posteromedial and ACL injuries with high-grade valgus and rotatory instability.

Injured vs. uninjured elbow opening on clinical stress radiographs and its relationship to ulnar collateral ligament injury severity in throwers

Stress radiography measures medial joint space opening of the elbow, but its value in the management of throwing athletes is unclear. The purpose of this study was to analyze the relationship between medial joint opening (gapping and excess opening) and ulnar collateral ligament (UCL) injury severity on magnetic resonance imaging, as well as to explore factors related to the unexpected finding of a greater opening of the uninjured elbow compared with the injured elbow (negative excess opening) with valgus stress radiography. Medial joint space measurements were independently performed by 2 raters in a clinical series of 74 patients evaluated with standardized valgus stress radiography as part of their clinical workup for throwing-related medial elbow pain. Demographic data were collected by chart review, and UCL injury severity was classified based on available imaging into intact UCLs, partial-thickness tears of the anterior bundle, or full-thickness tears of the anterior bundle. Joint gapping was related to UCL injury severity (P = .003), and group-level comparison showed a difference among tear severity groups (P = .050). Excess opening was not significantly related to UCL injury severity (P = .109). A negative excess opening was observed in 22% of patients, but no factors corroborating guarding or a mechanical explanation were significant for a decreased medial joint opening of the injured elbow compared with the uninjured elbow. Medial joint gapping was correlated to UCL injury severity in throwing athletes with medial elbow pain and a clinical suggestion of UCL injury, but no association between injury severity and excess opening was observed in this clinical series, which may limit the usefulness of stress radiography in the clinical workup of throwing athletes.

Treatment of Concomitant ACL and MCL Injuries: Spontaneous Healing of Complete ACL and MCL Tears.

The mainstay of treatment for anterior cruciate ligament (ACL) tear is considered to be surgery, especially when associated with medial collateral ligament (MCL) tears. We aimed to evaluate our hypothesis that some patients with concomitant ACL and MCL tears may develop spontaneous healing without surgical intervention. This study was conducted during 2013 to 2017. A total of 707 patient referred with combined ACL and MCL injuries. Patients were divided into three groups according to type of ACL and MCL management as follows: (1) group 1 as those who only had ACL reconstruction without any surgical treatment of MCL; (2) group 2 as those who had ACL reconstruction and MCL surgery (reconstruction, reefing, or both); (3) group 3 as those who showed spontaneous healing of ACL and MCL. Overall, 206 and 129 patients entered groups 1 and 2, respectively. Overall, 15 patients showed spontaneous healing of ACL and entered group 3. Skiing and soccer were the most common causes of injury within the third group, followed by traffic accidents (35.7%, 35.7% and 21.4%, respectively). All these were noncontact injuries within this groups. In group 3 only three patients had concomitant meniscal injury. Mean healing time for patient with spontaneous healing was 8.66 ± 3.41 months. All patients showed ACL tears at the proximal part of its attachment. During follow-up, all pivot shift, Lachman and MCL tests were either negative or one plus. All these individuals returned to previous physical activity. Among the total number of patients with skiing injuries presenting with concomitant ACL/MCL injuries (27 patients), five patients (18.5%) showed spontaneous healing. Valgus and external rotation injuries with dominancy of valgus force, apart from a MCL tear, may lead to proximal tear of ACL as well, and the inflammation from the torn MCL can potentiate and stimulate the healing process of ACL; thus, patient with this mechanism of injury is better followed before surgical intervention is planned as spontaneous healing may occur.

Medial Collateral Ligament Knee Injury in a Patient Receiving Rivaroxaban: A Cause of Acute Hemarthrosis

Medial collateral ligament (MCL) injury is highly common in athletes and the elderly. This ligament is in the knee region and is often at the risk of injury. Severe pain and motor limitation are the most important signs in the acute phase of the injury. In patients receiving anticoagulants, damage to the knee joint may lead to intra-articular bleeding, which exacerbates the symptoms and prolongs the recovery period. The present study aimed to describe the case of a 76-year-old woman with a sudden spin on the left knee while getting off a car. After a few minutes of walking, the patients felt pain, heard a pop-like sound on the injured knee, and was unable to walk, experiencing pain in the knee. The patient was transferred to the emergency department by the caregivers. The present case report was focused on the MCL injury in a patient receiving an anticoagulant due to atrial fibrillation.

Protein corona formation on particles in bovine synovial fluid and in a rat knee model of osteoarthritis

Purpose: In osteoarthritis (OA), molecular changes occur throughout the joint, causing changes in the joint milieu. Micro- and nanoparticles can be used to characterize these molecular changes. Specifically, proteins within the synovial fluid non-specifically adsorb onto the surface of particles. As such, changes in the protein corona formation on the particle surface may relate to molecular changes in OA. While protein corona formation is commonly studied in serum and cell culture media, it has not been assessed in OA animal models. In this study, protein corona formation was assessed in bovine synovial fluid and in a rat OA model. Methods: First, commercially available, magnetic microparticles (Dynabeads) were placed in bovine synovial fluid and separated using magnetic separation or centrifugation. The resulting protein corona was characterized using mass spectrometry. Then, 12 male and 12 female Lewis rats (9 weeks old) received a unilateral, simulated medial collateral ligament and meniscal injury. At 2, 5, or 8 weeks post-surgery, operated and contralateral limbs were injected with magnetic particles (n=4 per sex). After a 4-hour incubation, animals were euthanized, particles were recovered from the joint, and the protein corona was characterized using an Orbitrap Fusion Mass Spectrometer. Results: In bovine synovial fluid, a total of 116 proteins were identified, of which 35 were different between magnetic separation and centrifugation. In the rat OA model, 454, 464, and 342 proteins were identified at 2, 5, and 8 weeks post-surgery, respectively. Of the identified proteins on the particle surface, 35, 59, and 13 were different between the operated and contralateral limbs at 2, 5, and 8 weeks, respectively (p < 0.05, see Figure 1). Using principal component analysis, changes in the protein corona were found to relate with OA progression. Conclusions: Data from the bovine synovial fluid demonstrated that the protein corona that forms on the particle surface varies based on the method of particle separation from synovial fluid. Moreover, the in vivo data demonstrates that the protein corona layer on a particle surface changes at various stages of OA progression. Understanding how the particle-protein interface changes as a function of disease progression may be useful for biomarker discovery and informing the design of intra-articular drug delivery vehicles.

Arthroscopic anterior cruciate ligament reconstruction with semitendinosus graft versus peroneus longus tendon graft

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Arthroscopic anterior cruciate ligament (ACL) reconstruction can be performed using autograft from various sources namely, bone patellar tendon graft, hamstring tendons (semitendinosus, gracilis) or peroneus longus tendon.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study of 30 patients who underwent arthroscopic ACL reconstruction using quadrupled semitendinosus tendon autograft and peroneus longus tendon autograft during the study period.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Statistically, there is very little comparable difference between semitendinosus and peroneus longus when used for arthroscopic ACL reconstruction. However, peroneus longus tendon shows superior results when used in patients with grade 3 medial collateral ligament (MCL) injury combined with ACL injury.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Our study brings forth the superior efficacy and quality of the double stranded peroneus longus tendon especially in cases associated with complicated injuries involving the medial collateral ligament with a follow up date of about 2 years and as a healthy supplement to other choices of autografts and revision cases.&lt;/p&gt;

Classifications in Brief: The Schenck Classification of Knee Dislocations.

Classifications in Brief: The Schenck Classification of Knee Dislocations.

Valgus stress ultrasound for medial ulnar collateral ligament injuries in athletes: is ultrasound alone enough for diagnosis?

We hypothesized that valgus stress ultrasound would be useful for both identifying medial ulnar collateral ligament (MUCL) tears and assessing the severity of the tears. Hence, we performed valgus stress ultrasound of the elbow in athletes with MUCLinjuries, confirmed by magnetic resonance imaging (MRI), to determine whether ultrasound can be used as a diagnostic tool. Stress ultrasound and MRI data from 146 athletes with medial elbow pain were compared prospectively. MRI findings for MUCL injuries were classified into 3 levels as follows: low-grade partial tear (≤50%), high-grade partial tear (>50%), and complete tear. The degree of joint laxity on stress ultrasound was evaluated by measuring joint gapping after applying a 2.5-kg load to the wrist. Joint gapping was measured at 30° and 90° of elbow flexion for the dominant arm and nondominant arm, and the differences between the dominant and nondominant arms were determined. A higher degree of MUCL injury on MRI was associated with greater joint gapping in the medial elbow on stress ultrasound. At 30° of elbow flexion, the cutoff value for complete MUCL rupture was 0.5 mm (P < .001), with a sensitivity and specificity of 88.1% and 61.5%, respectively. At 90° of elbow flexion, the cutoff value for complete MUCL rupture was 1.0 mm (P < .001), with a sensitivity and specificity of 81.0% and 66.4%, respectively. Stress ultrasound can be used to diagnose complete MUCL tears in athletes when joint gapping is greater than 0.5 mm at 30° of elbow flexion and greater than 1 mm at 90° of elbow flexion.

Collateral Ligament Knee Injuries in Pediatric and Adolescent Athletes.

The majority of research on medial (MCL) and lateral (LCL) collateral ligament injuries has focused on adults and combined collateral/cruciate injuries. The purpose of this study was to determine characteristics associated with isolated collateral ligament injuries in adolescents, and assess timing for return to sports. Electronic medical records were queried to identify patients aged below 17 years who sustained a magnetic resonance imaging-confirmed isolated MCL or LCL injury over an 8-year period. Retrospective review then documented patient and injury characteristics and clinical course. General linear modeling was used to analyze risk factors for prolonged return to sports, continued pain or reinjury. Fifty-one knees (33 in males, 65%), mean age 13.8 years (range, 5 to 17), were identified, of which 40 (78%) had MCL injuries. Over half (29, 57%) of knees had an open distal femoral physis including all 5 bony avulsion injuries. Eleven (22%) had LCL injuries of which 3 (6%) had concurrent posterolateral corner injuries. Forty-two (82%) knees had injuries that occurred during sports. Eleven knees (28%) with MCL tears had a simultaneous patellar instability episode. Knee injuries that occurred during sports had 37% shorter recovery time (P=0.02). Eight knees (16%) experienced a reinjury and 12 (24%) were followed over an extended period of time for various knee issues. Football injuries were more likely to be grade 3 (P=0.03), and football and soccer accounted for all grade III injuries. The mean return to sports was 2.2 months, with grade III cases returning at 2.4 months, and 95% of cases within 4 months. Isolated collateral ligament injuries are rare in adolescent athletes. MCL injuries, one-quarter of which occurred in conjunction with patellar instability events, were 4 times more common than LCL injuries, one quarter of which have other posterolateral corner structures involved. Grade III injuries represent 20% to 25% of collateral ligament injuries and occurred most commonly in football and soccer. Level IV-retrospective case series.