Insertion Of Medial Collateral Ligament Research Articles

The Deep-MCL Line: A Reliable Anatomical Landmark to Optimize the Tibial Cut in UKA.

The extramedullary guides for the tibial resection during medial unicompartmental knee arthroplasty (UKA) are inaccurate, with an error risk in coronal and sagittal planes and cut thickness. It was our hypothesis that the use of anatomical landmarks for the tibial cut can help the surgeon to improve accuracy. The technique described in this paper is based on the use of a simple and reproducible anatomical landmark. This landmark is the line of insertion of the fibers of the deep medial collateral ligament (MCL) around the anterior half of the medial tibial plateau called the "Deep MCL insertion line". The used anatomical landmark determines the orientation (in the coronal and sagittal planes) and the thickness of the tibial cut. This landmark corresponds to the line of insertion of the fibers of the deep MCL around the anterior half of the medial tibial plateau. A consecutive series of patients who underwent primary medial UKA between 2019 and 2021 were retrospectively reviewed. A total of 50 UKA were included. The mean age at the time of surgery was 54.5 ± 6.6 years (44-79). The radiographic measurements showed very good to excellent intra-observer and inter-observer agreements. The limb and implant alignments and the tibial positioning were satisfying, with a low rate of outliers and good restoration of the native anatomy. The landmark of the insertion of deep MCL constitutes a reliable and reproducible reference for the tibial cut axis and thickness during medial UKA, independent of the wear severity.

Impacts of tibial plateau levelling osteotomy on the tibial insertion of the medial collateral ligament of the canine stifle joint – A cadaveric study

ObjectiveThe aim of this study was to assess the potential consequences of tibial plateau levelling osteotomy (TPLO) for the medial collateral ligament (MCL) tibial insertion (TI) with a particular focus on the effects of the TPLO planning technique and of the size of saw blade. Study designEighty-six stifle joints were collected from 43 canine cadavers and dissected free of soft tissue to expose the MCL. The MCL insertion sites were first identified with Chinese ink on intact stifle joints, and then marked with radio-opaque barium sulfate after removal of the MCL. Mediolateral radiographs were made of each marked stifle joint and used for TPLO digital planning. For each stifle, planning the TPLO was performed by centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia in group 1, and at the top of the intercondylar tubercles in group 2. Whenever possible, two saw blade sizes were tested in each group. Measurements were taken after TPLO simulation to assess how the procedure would alter the MCL TI. ResultsIn group 1, the integrity of the MCL TI was affected by the TPLO planning in 87.2% of the cases with the small saw blade and in 59.3% of the cases with the large blade, and in group 2, in 94.2% of the cases with the small and 77.9% with the large saw blade. In group 1, the osteotomy line was located above the TI, completely severing the MCL in four cases versus in 11 cases in group 2, while severing occurred in 14/15 cases with the small saw blade. ConclusionDuring TPLO, the osteotomy line transected the MCL TI in the majority of dogs. Centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia and using the largest saw size that preserves tibial tuberosity and patellar tendon insertion seems to be the best way to preserve the MCL TI as much as possible. Further research is needed to evaluate the clinical impact of MCL TI transection.

Traumatic Great Toe MCL Avulsion in Professional Athlete Treated Surgically with MCL Repair with Suture Tape Augmentation Allowing Rapid Return to Sport

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Acute medial collateral ligament (MCL) tears of the great toe metatarsophalangeal joint (MTPJ) are a rare occurrence. There is minimal literature existing regarding both operative and non-operative management of this pathology, also known as 'traumatic bunion' due to its low incidence. The closest analog is a traumatic ulnar collateral ligament (UCL) rupture in the hand (Skier's thumb). Suture anchor repair with an internal brace has proven to be an effective treatment for thumb UCL tears with rapid rehabilitation and early range of motion. This method has not yet been reported in literature for a weightbearing joint such as the hallux MTPJ. We present a case report for a professional surfer with traumatic great toe MCL avulsion with surgical technique allowing rapid return to sport. Methods: We present a case report of a novel technique for this rare traumatic MCL avulsion. Surgical management of the great toe MCL was performed utilizing a pre-loaded interference screw to fixate suture at the MCL origin with suture tape augmentation. A mid-axial medial approach was used with L-shaped capsular flap to expose the MCL. 3-0 braided suture was passed through the proximal avulsed MCL. A drill tunnel was prepared at the MCL origin, and the MCL was repaired to its anatomic origin with an interference screw technique for knotless technique. The interference screw was preloaded with suture tape. The suture tape from the interference screw was passed extra articular and the capsule was repaired. The sutuer tape was then inserted into the MCL insertion on the distal phalanx using a small interference screw and drill tunnel for a suture tape augmentation while the toe was held in neutral MTPJ position. Results: He was made weightbearing as tolerated in a CAM boot post-operatively. Immediate active great toe MTPJ motion was permitted. At 2 weeks post-op, sutures were removed, and he was allowed self-directed passive range of motion of the toe, with continued weightbearing as tolerated in the boot. All restrictions were lifted at 4 weeks for a return to play protocol and the patient resumed surfing immediately at that time. His last follow up appointment was at 3 months post-op, at which time he had resumed full activity, had no deformity recurrence, no pain, and his range of motion was symmetric to the contralateral foot. The patient was able to compete at full activity in a national tournament to continue the professional tour at 3 months post- operatively. Conclusion: This report demonstrates a novel surgical technique for the treatment of a rare traumatic MCL avulsion of the great toe (the 'traumatic bunion'). In this case of great toe MCL repair in a professional surfer, we utilized a knotless technique to repair the MCL to it's anatomic origin and also provide suture tape augmentation to allow rapid rehabilitation. This report demonstrates rapid return to sport, an excellent outcome, easy rehabilitation, and straightforward surgical technique. More research will be needed to demonstrate the success of this technique in a broader population.

Morphometric assessment of the medial collateral ligament of the canine stifle joint

ObjectiveThe study provides a morphometric assessment of the medial collateral ligament (MCL) of the canine stifle joint. Study designEighty-six stifle joints were collected from 43 canine cadavers and dissected to free them of soft tissue and expose the collateral ligaments. The MCL insertion sites were identified with Chinese ink on intact stifle joints and also marked with radiopaque paste after removal of the MCL. Mediolateral photographs and radiographs of each stifle joint were taken after MCL was removed for morphometric assessment. Measurements were taken in two groups: a group of Beagles (group 1), and a group composed of different breeds (group 2). ResultsIn all stifle joints, the MCL had an hourglass shape. It inserted in the distal femur and the proximal tibia, and was also intimately attached to the medial meniscus and more loosely to the proximal tibial epiphysis in its central portion. The MCL tibial insertion (TI) site had the largest surface area. Its proximal and distal position relative to the tibial plateau was located at 8.24 ± 1.17% and 15.54 ± 1.50% respectively of the total tibial length in group 1, and at 8.86 ± 1.93% and 15.53 ± 2.11% respectively, of the total tibial length in group 2. These values were not statistically different. ConclusionThe MCL of the canine stifle joint has an insertion site on the femur and on the tibia and is also attached on the medial meniscus. The location of the MCL TI site seems to be relatively homogeneous in dogs.

Treatment of Medial Collateral Ligament Injuries of the Knee with Focused Extracorporeal Shockwave Therapy: A Case Report

Medial collateral ligament (MCL) injuries are the most frequent ligamentous injuries of the knee. Focused extracorporeal shock wave therapy (f-ESWT) is progressively expanding its field of application to many musculoskeletal pathologies. Although there is evidence surrounding the efficacy of f-ESWT in tendinopathies, no studies have described the usefulness of ultrasound (US)-guided f-ESWT in the treatment of ligament injuries. Herein, we report a case of a MCL injury treated with f-ESWT. Moreover, our case shows the importance of using ultrasonography in determining the effect of treatment. A 60-year-old man with a focal area of lesion in the deep fibers underwent 4 weekly sessions of US-guided f-ESWT to the injured ligament area. His pain decreased to a visual analog scale (VAS) of 3 at the end of the treatment and was completely resolved at the 1-month follow-up visit, with these results being maintained at 4-month follow-up. The US examination showed an initial deposition of “newly formed tissue” at the site of previous injury of the proximal MCL insertion, and a reduction in MCL thickness together with an improvement in echostructure. Based on this result, we speculate that non-surgical ligament injuries could be a new indication for f-ESWT. However, further investigation on the effects of f-ESWT for ligament injuries is needed.

Length Change Pattern of the Medial Structures of the Knee and Related Reconstructions

Aims and Objectives:Chronic medial instability presents a severe problem both for the patient and the surgeon, and may result into anterior cruciate ligament graft failure in a combined anteromedial instability. Thus, reconstructions have been developed to conquer this problem. However, these are not capable of mimicking the flat anatomy of the medial structures of the knee. The goal of the present study was to examine the length change patterns of the native medial structures of the knee and their related reconstructions. It was hypothesised that the different portions of the medial collateral ligament present different length change patterns, which cannot be imitated by current reconstructions.Materials and Methods:Eight cadaveric knees were dissected of skin and subcutaneous fat. The satorius fascia was removed to get a clear vision of the medial structures. The knee was then mounted in a rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights, according to its fiber orientations and cross-sections. Threads attached to three tibial pins at the anterior/middle/posterior portion of the medial collateral ligament (MCL) were then guided to three femoral eyelets at the anterior/middle/posterior portion of the femoral MCL insertion and analogous with the tibial/femoral posterior oblique ligament (POL) insertion. A tibial pin was also put at the semitendinosus insertion to imitate the Lind reconstruction. Between 0-120 degree knee flexion, the distances between each possible tibiofemoral combination were measured using a linea variable differential transformer (LVDT). Statistical analysis was performed using two way repeated measurements ANOVA.Results:The anterior MCL showed an initial slackening (2%) until 20° flexion, followed by a tightening (5%) towards deep flexion (120°), meaning that it is tight in flexion. The posterior MCL also showed an initial slackening (4%) until 20° of flexion. However, then followed by an isometric area (20-80°) and a further slackening (8%) towards deep flexion (120°), meaning that it is tight in extension. The three portions of the POL showed a linear slackening between 0-120° (25%). The middle MCL showed a sine wave behaviour, slackening from 0- 60° (3%) and tightening between 60-100° (1%). This behaviour was similar in the Lind and Robinson reconstruction, which were the most isometric tibiofemoral combinations (total strain range: 5,3 ± 2,1). The native POL length changes showed the most non-isometric behaviour resulting into a total strain range of 28,8 ± 6,2, which was significantly different from the native MCL and MCL reconstructions (p< .001)Conclusion:The anterior, middle, and posterior parts of the MCL showed different length change patterns. The anterior part tightened in flexion, whereas the posterior part tightened in extension. This behavior could not be reproduced by the current reconstructions, such as the Lind and Robinson procedure, which only could imitate the middle portion of the native MCL.

Anatomic Dissection and CT Imaging of the Anterior Cruciate and Medial Collateral Ligament Footprint Anatomy in Skeletally Immature Cadaver Knees.

Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in skeletally immature patients are increasingly recognized and surgically treated. However, the relationship between the footprint anatomy and the physes are not clearly defined. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and define the footprint anatomy in relation to the physes in skeletally immature knees. Twenty-nine skeletally immature knees from 16 human cadaver specimens were dissected and divided into 2 groups: group A (aged 2 to 5 y), and group B (aged 7 to 11 y). Metallic markers were placed to mark the femoral and tibial attachments of the ACL and MCL. Computed tomography scans were obtained for each specimen used to measure the distance from the center of the ligament footprints to the respective distal femoral and proximal tibial physes. The median distance from the ACL femoral epiphyseal origin to the distal femoral physis was 0.30 cm (interquartile range, 0.20 to 0.50 cm) and 0.70 cm (interquartile range, 0.45 to 0.90 cm) for groups A and B, respectively. The median distance from the ACL epiphyseal tibial insertion to the proximal tibial physis for groups A and B were 1.50 cm (interquartile range, 1.40 to 1.60 cm) and 1.80 cm (interquartile range, 1.60 to 1.85 cm), respectively. The median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20 cm (interquartile range, 1.00 to 1.20 cm) and 0.85 cm (interquartile range, 0.63 to 1.00 cm) for groups A and B, respectively. The median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05 cm (interquartile range, 2.63 to 3.30 cm) and 4.80 cm (interquartile range, 3.90 to 5.10 cm) for groups A and B, respectively. Surgical reconstruction is a common treatment for ACL injury. Computed tomography scanning of pediatric tissue clearly defines the location of the ACL and MCL with respect to the femoral and tibial physes, and may guide surgeons for physeal respecting procedures. In addition to ACL reconstruction, recent basic science and clinical research suggest that ACL repair may be more commonly performed in the future. MCL repair and reconstruction is also occasionally required in skeletally immature patients. This information may be useful to help surgeons avoid or minimize physeal injury during ACL/MCL reconstructions and/or repair in skeletally immature patients.

Throwing Activities Among Neolithic Populations from the Meuse River Basin (Belgium, 4500–2500 BC) with a Focus on Adolescents

ABSTRACTThe anterior band of the medial collateral ligament (MCL) is an important stabilizer for valgus stress at the elbow. When practised intensively and repetitively, activities using overhead throwing motions can injure this ligament and its insertion. If these activities occur when the epiphyses are not yet fully fused, traction forces can result in bony detachments in the area of the MCL insertion. This study was based on commingled graves found in 16 Middle and Late Neolithic caves from Belgium. We recorded the presence of MCL lesions on 196 humeri and studied the relation between lesions, siding, and robusticity. 5.1% of the humeri displayed MCL lesions, which affected only the right robust humeri. Our results suggest a social division in throwing activities in Belgium during the Neolithic. They also suggest that throwing practice started from a young age, which invites us to re-examine the role of teenagers in prehistoric societies.

ANATOMICAL DISSECTION AND CT IMAGING OF THE ANTERIOR CRUCIATE AND MEDIAL COLLATERAL LIGAMENT FOOTPRINT ANATOMY IN SKELETALLY IMMATURE CADAVER KNEES

Background: Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in skeletally immature patients are increasingly recognized and surgically treated. However, the relationship between the footprint anatomy and the physes are not clearly defined. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and define the footprint anatomy in relation to the physes in skeletally immature knees. Methods: Twenty-nine skeletally immature knees from 16 human cadaver specimens were dissected and divided into two groups: Group A (ages 2-5 years), and Group B (ages 7-11 years). Metallic markers were placed to mark the femoral and tibial attachments of the ACL and MCL. CT scans were obtained for each specimen used to measure the distance from the center of the ligament footprints to the respective distal femoral and proximal tibial physes. Results: Median distance from the ACL femoral epiphyseal origin to the distal femoral physis was 0.30 cm (interquartile range, 0.20 cm to 0.50 cm) and 0.70 cm (interquartile range, 0.45 cm to 0.90 cm) for Groups A and B, respectively. The median distance from the ACL epiphyseal tibial insertion to the proximal tibial physis for Groups A and B were 1.50 cm (interquartile range, 1.40 cm to 1.60 cm) and 1.80 cm (interquartile range, 1.60 cm to 1.85 cm), respectively. Median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20 cm (interquartile range, 1.00 cm to 1.20 cm) and 0.85 cm (interquartile range, 0.63 cm to 1.00 cm) for Groups A and B, respectively. Median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05 cm (interquartile range, 2.63 cm to 3.30 cm) and 4.80 cm (interquartile range, 3.90 cm to 5.10 cm) for Groups A and B, respectively. Conclusion: Surgical reconstruction is a common treatment for ACL injury, and occasionally MCL reconstruction or repair is also required. Cadaveric dissection and CT scanning of exceptionally rare pediatric tissue clearly defines the location of the ACL and MCL with respect to the femoral and tibial physes, and may guide surgeons for physeal respecting procedures for both ACL reconstruction, and ACL repair procedures. Clinical Relevance: In addition to ACL reconstruction, recent basic science and clinical research suggest that ACL repair may be more commonly performed in the future. MCL repair and reconstruction is also occasionally required in skeletally immature patients. This information may be useful to help surgeons avoid or minimize physeal injury during ACL/MCL reconstructions and/or repair in skeletally immature patients. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

The remarkable migration of the medial collateral ligament

The developing cortical surfaces of long bones are sculpted and modeled by periosteal osteoclasts and osteoblasts. These surfaces also receive the insertions of tendons and ligaments, and these insertion sites too are modeled to form the root systems that anchor them into the cortical bone. The regulatory molecules that control modeling are poorly understood, but recent evidence suggests that parathyroid hormone-related protein (PTHrP) participates in this process. PTHrP functions principally as a paracrine regulatory molecule, and is known to be induced by mechanical loading in a number of sites. The most curious example of developmental modeling of the cortex is the migration of insertion sites such as that of the medial collateral ligament (MCL) along the bone surface during long-bone growth. We report here the mechanisms that mediate MCL migration using a combination of genetic, imaging and histological techniques. We describe a MCL migratory complex that comprises two components. The first is the MCL insertion site itself, which is a prototypical fibrous insertion site with coupled osteoclast and osteoblast activities, and its key feature is that it is anchored early in development, well before initiation of the long-bone growth spurt. Above the insertion site the periosteum is excavated by osteoclasts to form a migratory tract; this is mediated by wholly uncoupled osteoclastic bone resorption and remains as an unmineralized canal on the cortical surface in the adult. Load-induction of PTHrP appears to regulate the osteoclastic activity in both the insertion site and migratory tract.

Does a conservative tibial cut in conventional total knee arthroplasty violate the deep medial collateral ligament?

Based on the anatomy of the deep medial collateral ligament (MCL), it was hypothesized that at least part of its cross-sectional insertion area is jeopardized while performing a standard tibial cut in conventional total knee arthroplasty (TKA). The aim of this study was to determine whether it is anatomically possible to preserve the tibial deep MCL insertion during conventional TKA. Thirty-three unpaired cadaveric knee specimens were used for this study. Knees with severe varus/valgus deformity or damage to the medial structures of the knee were excluded. In the first part of the study, the dimensions of the tibial insertion of the deep MCL and its relationship to the joint line were recorded. Next, the cross-sectional area of the deep MCL insertion was determined using calibrated digital photographic analysis. In the second part, the effect of a standard 9-mm 3° sloped tibial cut on the structural integrity of the deep MCL cross-sectional insertion area was determined using conventional instrumentation. The proximal border of the deep MCL insertion site on the tibia was located on average 4.7 ± 1.2 mm distally to the joint line. After performing a standard 9-mm 3° sloped tibial cut, on average 54% of the deep MCL insertion area was resected. In 29% of the cases, the deep MCL insertion area was completely excised. The deep MCL cannot routinely be preserved in conventional TKA. The deep MCL insertion is at risk and may be jeopardized in case of a tibial cut 9 mm below the native joint line. As the deep MCL is a distinct medial stabilizer and plays an important role in rotational stability, this may have implications in future designs of both unicondylar and total knee arthroplasty, but further research is necessary.

Anatomical Dissection and CT Imaging of the Anterior Cruciate and Medial Collateral Ligaments in Skeletally Immature Cadaver Knees

Objectives:Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) are increasingly recognized in skeletally immature patients. Although most MCL injuries heal, some may require reconstruction. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and determine the attachment locations in relation to the physes in skeletally immature knees.Methods:Seven skeletally immature cadaver knee specimens were dissected. These specimens were divided into two groups: Infants (ages-1, 11, and 11 months), and Children (ages 8, 10, 11, and 11 years). Metallic markers were placed at the midpoint of the femoral origins and tibial insertions of the ACL and MCL. CT scans with 1mm slices were obtained for each specimen and were analyzed using Osirix Imaging Software. The distance from both the ACL and MCL femoral origin midpoints to the distal femoral physis was measured. The distance from the ligaments’ insertion midpoints to the proximal tibial physis was measured.Results:The mean distance from the ACL origin midpoint to the femoral physis was 0.63 cm (0.58-0.68 cm) and 0.85 cm (0.75-0.97 cm) distal to the physis for infants and children, respectively. The mean distance from the MCL origin midpoint to the lowest point of the femoral physis was 0.78 cm distal to the physis for one infant. For 2/3 children, this measurement was 0.60 cm distal to the physis, and 0.37 cm proximal to the physis for one child. In three specimens, this measurement could not be taken. The mean distance from ACL insertion midpoint to the proximal tibial physis was 0.39 cm (0.62-1.15 cm) and 1.74 cm (1.46-2.15 cm) proximal to the physis for infants and children, respectively. The mean distance from the MCL insertion midpoint to the tibial physis was 0.76 cm (0-2.28 cm) and 3.52 cm (2.29-4.60 cm) distal to the physis for infants and children, respectively.Conclusion:Pediatric cadaver tissue is very difficult to obtain for research, and many anatomic studies in skeletally immature patients are based on MRI sequences. This cadaveric dissection with CT scan clarifies the location of the ACL and MCL with respect to the femoral and tibial physes. This information may be useful to help surgeons avoid physeal injury during ACL/MCL reconstructions in skeletally immature patients.

The effect of medial side repair in terrible triad injury of the elbow

The aim of this study was to evaluate the effect of surgical repair of the medial collateral ligament and ulnar nerve release in cases of terrible triad injuries of the elbow. This study included 16 patients (average age: 34 years) who underwent surgery following a diagnosis of terrible triad injury of the elbow between 1996 and 2007. Average follow up was 34.5 months. In all cases, the radial head was first fixed or replaced and the anterior capsule/coronoid complex and lateral collateral ligament were repaired. The medial side of the elbow was addressed (medial collateral ligament repair and ulnar nerve release) in 8 cases and not addressed in the remaining 8 cases. Range of motion, pain, stability, ulnar nerve symptoms, functional Mayo Elbow Performance Index, and Disabilities of the Arm, Shoulder and Hand scores were documented. Serial X-rays were used to confirm ulnohumeral arthritis and development of ectopic calcification. Ultrasonography or MRI was used to detect ulnar nerve entrapment. Range of motion was slightly more limited in cases where the medial side was not addressed. Ulnohumeral range of motion and flexion degrees were higher in the cases where the medial side was addressed (p<0.05). Serial X-rays demonstrated impending ectopic calcification located at the proximal insertion of medial collateral ligament in patients who did not undergo medial side repair. MRI or ultrasonography confirmed these findings, revealing swollen displaced nerves resembling findings similar to cubital tunnel syndrome. Ulnar neuropathy is a common complication after medial collateral ligament injury and prophylactic release will facilitate overall results and postoperative patient satisfaction.

Potential Iatrogenic Medial Meniscal Damage During Tibial Plateau Leveling Osteotomy

To evaluate potential iatrogenic medial meniscal (MM) damage during tibial plateau leveling osteotomy (TPLO) and to establish a safe zone (SZ) for hypodermic needle (HN) identification of the medial aspect of the stifle joint. Prospective cohort. Cadaveric canine stifles (n=40). HN (20 or 25 G) were inserted through the medial collateral ligament (MCL) of the femorotibial joint and through the SZ insertion points. The medial meniscus was inspected for iatrogenic damage. Statistical comparison of MM damage caused by different needle sizes and insertion sites was performed using Fisher's exact test with significance at P< .05. Twenty-gauge group: 65% of stifles had minor MM damage with MCL insertion compared with 35% of stifles with SZ insertion (P=.0049). Severe MM damage occurred in 25% of stifles with MCL insertion compared with 0% of stifles with SZ insertion (P=.0014). Twenty-five-gauge group: 85% of stifles had minor MM damage with MCL insertion compared with 30% after SZ insertion (P=.0011); however, no severe MM injury was noted. HN insertion though the MCL can produce iatrogenic damage to the MM. Use of a 25 G HN and SZ site for insertion reduced the frequency and severity of MM damage. HN insertion into the medial aspect of the femorotibial joint during TPLO can cause gross iatrogenic MM damage, which may contribute to the incidence and misdiagnosis of latent MM injuries after TPLO.

Single–Achilles Allograft Posterior Cruciate Ligament and Medial Collateral Ligament Reconstruction: A Technique to Avoid Osseous Tunnel Intersection, Improve Construct Stiffness, and Save on Allograft Utilization

We present a method for single–Achilles allograft medial collateral ligament (MCL) and posterior cruciate ligament (PCL) reconstruction that eliminates the risk of tunnel intersection, stiffens the construct, and maximizes utilization of allograft tissue. An Achilles tendon allograft is prepared with an 11- to 12-mm bone plug with a gradual taper to 7 mm over approximately 15 cm. A transtibial PCL tunnel is created under fluoroscopic and arthroscopic guidance. The femoral tunnel is prepared in an “outside-in” fashion under direct arthroscopic visualization, originating at the anatomic origin of the MCL on the medial epicondyle and entering the joint at the anatomic origin of the anterolateral bundle of the PCL. The Achilles graft is pulled into the joint through the tibial tunnel and routed into the femoral tunnel so that the soft tissue exits at the medial epicondyle. The bone plug is fluoroscopically guided to the posterior aperture of the tibial tunnel and fixed with a bioabsorbable interference screw. The pretensioned graft is fixed in the femoral tunnel via interference screw fixation with the knee in 90° of flexion. The isometric position of the MCL insertion is identified with a K-wire isometer, and the graft is fixed in place at this point by use of an interference screw or screw and washer.

Surgical treatment of medial collateral ligament laxity complicated by old cruciate ligament injury of the knee

To investigate the therapeutic effect of transposition of semitendinosus tendon combined with femur insertion of medial collateral ligament (MCL) and reconstruction of anterior cruciate ligament (ACL) with autograft bone-patellar tendon-bone in treatment of MCL laxity complicated by ACL injury of the knee. Twenty patients (20 knees), 14 male and 6 female, aged 32.6 (16-64), 1 case at grade II and 19 cases at grade III according to X ray classification, all cases at grade III by MRI evaluation, and with preoperative Lysholm knee joint score of 48.9 (35-65), underwent transposition of semitendinosus tendon combined with femur insertion of medial collateral ligament (MCL) and reconstruction of anterior cruciate ligament (ACL) with autograft bone-patellar tendon-bone. Followed up was conducted for 19.2 (6-59) months. The postoperative Lysholm score was 83.9 (50-96). Eighteen of the 20 patients obtained an excellent result with good function of the knee joint except one case with osteoarthritis and one case with limited range of motion of the knee (90 degree), and the good-to-excellent rate was 90%. Reconstruction with autograft of the bone-patellar tendon-bone and transposition of semitendinosus tendon combined with femur insertion of MCL proximal transfer is a reliable treatment method for MCL laxity complicated by old ACL injury of the knee.

Medial collateral ligament insertion site and contact forces in the ACL-deficient knee

The objectives of this research were to determine the effects of anterior cruciate ligament (ACL) deficiency on medial collateral ligament (MCL) insertion site and contact forces during anterior tibial loading and valgus loading using a combined experimental-finite element (FE) approach. Our hypothesis was that ACL deficiency would increase MCL insertion site forces at the attachments to the tibia and femur and increase contact forces between the MCL and these bones. Six male knees were subjected to varus-valgus and anterior-posterior loading at flexion angles of 0 degrees and 30 degrees. Three-dimensional joint kinematics and MCL strains were recorded during kinematic testing. Following testing, the MCL of each knee was removed to establish a stress-free reference configuration. An FE model of the femur-MCL-tibia complex was constructed for each knee to simulate valgus rotation and anterior translation at 0 degrees and 30 degrees, using subject-specific bone and ligament geometry and joint kinematics. A transversely isotropic hyperelastic material model with average material coefficients taken from a previous study was used to represent the MCL. Subject-specific MCL in situ strain distributions were used in each model. Insertion site and contact forces were determined from the FE analyses. FE predictions were validated by comparing MCL fiber strains to experimental measurements. The subject-specific FE predictions of MCL fiber stretch correlated well with the experimentally measured values (R2 = 0.95). ACL deficiency caused a significant increase in MCL insertion site and contact forces in response to anterior tibial loading. In contrast, ACL deficiency did not significantly increase MCL insertion site and contact forces in response to valgus loading, demonstrating that the ACL is not a restraint to valgus rotation in knees that have an intact MCL. When evaluating valgus laxity in the ACL-deficient knee, increased valgus laxity indicates a compromised MCL.

Bisphosphonates reduce bone mineral loss at ligament entheses after joint injury

To examine the effects of anterior cruciate ligament (ACL) insufficiency, and subsequent bisphosphonate (BP) antiresorptive therapy, on the bone mineral interface at the enthesis of remaining ligamentous restraints. We measured bone mineral geometry (and subsequent adaptation) at the medial collateral ligament (MCL) origin, using micro-computed tomography (muCT). Groups of normal control, 6 and 14 wk anterior cruciate ligament transected (ACLX), and 6 wk ACLX-BP (risedronate) dosed rabbits were evaluated. Samples were then processed histologically, and the results of mineral adaptation and progression of osteoarthritis (OA) compared to joint laxity values obtained from previous biomechanical testing of the MCL-complex. muCT defined the MCL origin as a symmetrical, metaphyseal depression that contained soft-tissue elements, including fibrocartilage and ligament--as seen in subsequent histological sections. In contrast, the insertions from ACLX animals lost significant bone mineral, with an MCL-insertion volume 1.2 times that of normal controls at 6 wk ACLX, which further increased to 2.3 times that of normal controls at 14 wk ACLX. Significant differences were also measured between 6 and 14 wk ACLX and age-matched normal controls in volume of cortical bone containing the MCL insertion. However, there were no significant differences in the percentage of cortical bone to underlying trabecular bone at the MCL insertion. When comparing muCT mineral adaptation at the MCL-enthesis with historical MCL-complex laxity data, the values for laxity after ACLX increased proportionately as bone mineral at the insertion was lost, and subsequent use of the BP risedronate reduced both mineral loss and MCL-complex laxity. Compared to the untreated ACLX condition, administering bisphosphonate immediately after loss of the ACL conserved bone mineral at the MCL enthesis, suggesting the potential to therapeutically influence joint-complex laxity and OA progression.

Post traumatic osteoma of tibial insertion of medial collateral ligament of knee joint.

Two cases are presented of post traumatic para-articular osteoma developing at the site of tibial attachment of the medial collateral ligament of knee joint. These occurred after injuries sustained while...

The postnatal development of the insertions of the medial collateral ligament in the rat knee

Bone soft tissue remodelling at the femoral and tibial insertions of the medial collateral ligament (MCL) of the rat knee was monitored at regular intervals from birth to 120 days of age in 40 Sprague Dawley rats. At birth the femoral insertion originated from the perichondrium of the epiphysis. By day 8 the perichondrium within the insertion had turned into fibrocartilage. Secondary ossification of the femoral epiphysis had progressed in the region near to the insertion site by day 15. The epiphyseal cartilage was entirely replaced by bone by day 40 except for the fibrocartilage within the insertion. After that stage, no qualitative change in zonal insertion characteristics was observed, but only increase in size and decrease in cellularity. At birth, the tibial ligament inserted onto the thin cortical bone of the metaphysis via periosteum. At day 8, osteoclasts started to resorb the thin cortical bone at the ligament insertion, thus forming a metaphyseal depression between days 10 and 20. From days 20 to 120, the insertion remained qualitatively unchanged, showing three zones, the ligament, periosteum, and metaphyseal trabecular bone. The deep periosteal layer showed osteoclastic activity in the proximal part and osteoblastic activity in the distal part. The migration-mechanism of the ligament insertion during growth seems to be caused by this growth-related osteoclastic resorption of the proximal metaphyseal bone and by simultaneous osteogenic activity, which successively cements the distal part of the ligament to bone. The persistence of the periosteal layer and the metaphyseal depression for up to 120 days may be regarded as a sign of continuing growth in this animal model. This is the first investigation showing that the formation of the metaphyseal depression is a purely postnatal event, and suggests that this process might be initiated by the change in mode of growth and joint biomechanics after birth, enabling ligament development and migration in a growing and increasingly loaded weight-bearing joint. The mainly resorptive process, which takes place during development of the tibial MCL insertion, may account for the tensile failure of this ligament that commonly occurs at this site during growth. The pronounced morphological differences between the chondral femoral and the periosteal tibial attachment of the adult MCL are apparently caused by the different postnatal development processes at epiphyses and metaphyses.