Medial Collateral Ligament Insufficiency Research Articles

A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques

Background: There is little evidence of the biomechanical performance of medial collateral ligament (MCL) reconstructions for restoring stability to the MCL-deficient knee regarding valgus, external rotation (ER), and anteromedial rotatory instability (AMRI). Hypothesis: A short isometric reconstruction will better restore stability than a longer superficial MCL (sMCL) reconstruction, and an additional deep MCL (dMCL) graft will better control ER and AMRI than single-strand reconstructions. Study Design: Controlled laboratory study. Methods: Nine cadaveric human knees were tested in a kinematics rig that allowed tibial loading while the knee was flexed-extended 0° to 100°. Optical markers were placed on the femur and tibia and displacements were measured using a stereo camera system. The knee was tested intact, and then after MCL (sMCL + dMCL) transection, and loaded in anterior tibial translation (ATT), ER, varus-valgus, and combined ATT + ER (AMRI loading). Five different isometric MCL reconstructions were tested: isolated long sMCL, a short construct, each with and without dMCL addition, and isolated dMCL reconstruction, using an 8 mm–wide synthetic graft. Results: MCL deficiency caused an increase in ER of 4° at 0° of flexion (P = .271) up to 14° at 100° of flexion (P = .002), and valgus laxity increased by 5° to 8° between 0° and 100° of flexion (P < .024 at 0°-90°). ATT did not increase significantly in isolated MCL deficiency (P > .999). All 5 reconstructions restored native stability across the arc of flexion apart from the isolated long sMCL, which demonstrated residual ER instability (P≤ .047 vs other reconstructions). Conclusion: All tested techniques apart from the isolated long sMCL graft are satisfactory in the context of restoring the valgus, ER, and AMRI stability to the MCL-deficient knee in a cadaveric model. Clinical Relevance: Contemporary MCL reconstruction techniques fail to control ER and therefore AMRI as they use a long sMCL graft and do not address the dMCL. This study compares 5 MCL reconstruction techniques. Both long and short isometric constructs other than the long sMCL achieved native stability in valgus and ER/AMRI. Double-strand reconstructions (sMCL + dMCL) tended to provide more stability. This study shows which reconstructions demonstrate the best biomechanical performance, informs surgical reconstruction techniques for AMRI, and questions the efficacy of current popular techniques.

A case series of total knee arthroplasty with a non-constrained implant in 2nd and 3rd degree valgus deformity in knee osteoarthritis and medial collateral ligament insufficiency

IntroductionOsteoarthritis is one of the leading causes of disability and the most common degenerative disease of the knee that causes enormous pain. As many as 10–15 % of patients requiring total knee arthroplasty (TKA) present with valgus knee deformity. When fully constrained TKA is not possible, the surgeon must use a different method to achieve a good result. Case descriptionA 56-year-old female with 3rd degree (48-degree) and a 62-year-old male with 2nd degree valgus knee (13-degree) with painful osteoarthritis were examined. Both have valgus thrust gait and medial collateral ligament (MCL) laxity and underwent TKA using non-constrained implants. During surgical exposure, MCL insufficiency was found in both patients, and MCL augmentation was performed. Post-operative assessment and 4-month follow-up were done through clinical and radiological parameters using the knee scoring system. DiscussionA good outcome could still be achieved with a primary TKA implant in severe and moderate valgus knees with MCL insufficiency using MCL augmentation. The primary TKA implant proved to improve clinical and radiological parameters after 4 months of follow-up. Clinically, both patients no longer felt pain in their knees and were able to walk with better stability. Radiologically, there was a much-reduced valgus degree. The results were the first case went from 48-degree to 2-degree and the second case went from 13-degree to 6-degree. ConclusionKnee osteoarthritis with valgus deformity and MCL insufficiency present surgical challenges during TKA. It is still possible to use in severe or moderate valgus with MCL insufficiency, which was proven by satisfactory clinical and radiological findings. Although a non-constrained option is not ideal, it is still the first choice in certain cases.

Medial Collateral Ligament Reconstruction for Anteromedial Instability of the Knee: A Biomechanical Study In Vitro

Background: Although a medial collateral ligament (MCL) injury is associated with anteromedial rotatory instability (AMRI) and often with an anterior cruciate ligament (ACL) injury, there has been little work to develop anteromedial (AM) reconstruction to address this laxity. Purpose: To measure the ability of a novel “anatomic” AM reconstruction technique to restore native knee laxity for isolated AM insufficiency and combined AM plus posteromedial insufficiency. Study Design: Controlled laboratory study. Methods: A total of 12 cadaveric knees were mounted in a kinematic testing rig that allowed the tibia to be loaded while the knee flexed-extended 0° to 100° with 88-N anteroposterior translation, 5-N·m internal rotation–external rotation (ER), 8-N·m valgus, and combined anterior translation plus ER to simulate AMRI. Joint motion was measured using optical trackers with the knee intact, after superficial MCL (sMCL) and deep MCL (dMCL) transection, and after AM reconstruction of the sMCL and dMCL with semitendinosus autografts. The posteromedial capsule (PMC)/posterior oblique ligament (POL) was then transected to induce a grade 3 medial injury, and kinematic measurements were repeated afterward and again after removing the grafts. Laxity changes were examined using repeated-measures analysis of variance and post-testing. Results: sMCL and dMCL deficiency increased valgus, ER, and AMRI laxities. These laxities did not differ from native values after AM reconstruction. Additional PMC/POL deficiency did not increase these laxities significantly but did increase internal rotation laxity near knee extension; this was not controlled by AM reconstruction. Conclusion: AM reconstruction eliminated AMRI after transection of the dMCL and sMCL, and also eliminated AMRI after additional PMC/POL transection. Clinical Relevance: Many MCL injuries occur in combination with ACL injuries, causing AMRI. These injuries may rupture the AM capsule and dMCL. Unaddressed MCL deficiency leads to an increased ACL reconstruction failure rate. A dMCL construct oriented anterodistally across the medial joint line, along with an sMCL graft, can restore native knee ER laxity. PMC/POL lesions did not contribute to AMRI.

The role of the flexor pronator muscles as dynamic stabilizers against elbow valgus stress in patients with medial ulnar collateral ligament insufficiency.

The flexor pronator muscles (FPMs) have been reported to act as dynamic stabilizers against valgus forces in overhead-throwing athletes. Several studies have demonstrated the anatomic, biomechanical, and clinical effects of the FPMs. However, no studies have investigated the invivo kinematics of the FPMs against the valgus forces on the elbow. This study aimed to clarify the clinical contribution of the FPMs as dynamic stabilizers in medial ulnar collateral ligament (MUCL) insufficiency. Eighteen baseball players with MUCL injury participated in this study. The elbow was flexed to 90°, and the forearm was placed in the supinated position. Manual valgus stress was applied to the elbow joint until maximal shoulder external rotation was achieved. The width of the ulnohumeral joint space was measured using ultrasonography, and any changes in medial elbow pain were recorded before and after isometric forearm pronation. All the subjects had MUCL tenderness and felt medial elbow pain when elbow valgus stress was applied. The width of the medial joint space was significantly larger on the injured side than on the healthy side (5.1 ± 1.0 mm vs. 3.2 ± 1.0 mm) with elbow valgus stress. During isometric forearm pronation, the width of the medial joint space was significantly decreased (3.1 ± 0.9 mm vs. 2.6 ± 1.0 mm) and medial elbow pain had completely diminished. Isometric forearm pronation reduces valgus stress-induced widening of the medial joint space and medial elbow pain in patients with MUCL insufficiency.

The influence of chronic medial epicondylar apophysitis on medial ulnar collateral ligament insufficiency-: a retrospective cohort study.

BackgroundThis study aimed to investigate the effect of chronic traction apophysitis of the medial epicondyle (MEC) on medial ulnar collateral ligament (MUCL) insufficiency in high school baseball players.MethodsIn this retrospective cohort study, 3034 of 6069 high school baseball players were enrolled. A self-reported questionnaire was distributed to investigate past history of elbow pain and elbow pain during the previous season. Physical examinations to assess tenderness on the MUCL and the elbow valgus stress test (EVST) were performed. Ultrasonography was performed to determine the presence of morphological abnormalities of the anteroinferior aspect of the MEC (MEC lesions).ResultsParticipants with MEC lesions had a significantly higher prevalence of past history of elbow pain, elbow pain during the previous season, MUCL tenderness, and positive EVST than those without MEC lesions (P < .05). Multivariate logistic regression analysis revealed that the participants with the fragmented type had the highest risk of past history of elbow pain (odds ratio [OR] = 3.94), elbow pain during the previous season (OR = 2.27), positive EVST (OR = 3.49), and the second highest risk of MUCL tenderness (OR = 2.01) followed by the irregular type (OR = 2.31). Participants with the hypertrophic type had the lowest risk of past history of elbow pain (OR = 2.08), elbow pain during the previous season (OR = 1.42), MUCL tenderness (OR = 1.09), and positive EVST (OR = 1.47).ConclusionThe presence of chronic non-healed traction apophysitis of the MEC in high school baseball players presented a significantly high risk of elbow pain and MUCL insufficiency.

Use of External Approach for Severe Genu Valgo Knee Arthroplasty

The deformities of the lower limbs (genu valgus and genu varus) are alterations frequently developed properly by physiological processes which usually disappear at 2 years (genu varus) and at 7-8 years (genu valgus), being considered in adults normal a 4º-6º genu valgus, however the appearance of the latter is also related to various metabolic pathologies, tumors, traumatic sequelae, infections, skeletal dysplastic and idiopathic genu valgus. In the bibliography, there is a greater consensus on the approach to varus deformity, not so in valgus deformities, where there is no bibliography with a level of evidence that defines established protocols to treat severe valgus deformities&gt;20, currently good treatment results have been demonstrated by means of knee arthroplasty to correct genu valgus deformities, which showed good results in the alignment of the lower extremities through the balance of ligaments in patients with severe genu valgus with pain reduction. , improvements in knee function and with a low rate of complications, the use of these alternatives such as the external approach in total knee replacement in patients with severe genu valgus and medial collateral ligament insufficiency allows correcting large deformities using a technique simple and in most cases without the use of a prosthesis that generates a degree of constraint, progressively improving their living conditions.

Single-Row Repair in Chronic Medial Collateral Ligament Insufficiency

AbstractMedial collateral ligament (MCL) is the most commonly injured ligament of the knee. Acute Grade III MCL injuries can be managed conservatively except bony avulsion, intra-articular entrapment and Stener lesion, which requires surgical treatment by repair with or without augmentation. Chronic MCL injuries are treated surgically with various reconstruction techniques that are well established in the literature, which requires use of autograft or allograft and multiple tunnel placement with multiple implants for graft fixation. These techniques possess higher chances of tunnel convergence and hardware-related complications, further increasing surgery cost, especially for multi ligament injuries. Finally, all these MCL reconstruction surgeries are technically challenging. Here, we propose our technique of single-row repair in cases of chronic femoral side MCL insufficiency with grade III valgus laxity. This technique reattaches the torn ligament at its near anatomical attachment site using a single, double-loaded 5.5-mm suture anchor. This technique preserves and uses the native MCL, requiring no separate graft and no tunnel preparation. Hence, no graft site morbidity and tunnel-related complications, along with maintenance of proprioception. It is a cost-effective, reproducible, and technically simple procedure with good functional outcome. Level Iknee Level IIcollateral ligaments

Management of Medial Collateral Ligament Insufficiency During Total Knee Arthroplasty with a Screw and Rectangular Spiked Washer: A Case Series of 14 Patients

ObjectiveTo describe the technique of primary repair of medial collateral ligament (MCL) insufficiency using a screw and rectangular spiked washer in a case series of 14 patients.MethodsFourteen patients undergoing MCL repair by a screw and rectangular spiked washer during TKA between March 2018 and March 2019 were retrospectively reviewed. Among them, half injuries were avulsion of the femoral origin, and the other half were MCL laxity. There were 12 women and two men included in the study, with an average age of 63.6 years (range, 49–79 years) at the time of surgery. This series were followed up with a focus on range of motion (ROM), coronal alignment, Hospital for Special Surgery (HSS) knee scores, their subjective sense of joint instability, and related complications. At the last follow‐up, function of the MCL was assessed by manually applying a valgus stress to the knee at both 0° and 30° of knee flexion.ResultsThe mean follow‐up time for all patients was 15.6 months (range, 13–20 months). Repair of the MCL was successful in all patients. ROM improved from a mean of 70.7° ± 35.1° before surgery to 103.9° ± 6.8° at latest follow‐up (P = 0.001). All patients were able to perform a half squat easily, but none were able to do full squatting. The mean preoperative HSS score was 43.6 ± 13.4 and increased to a mean of 85.6 ± 3.8 postoperatively (P < 0.001). The femorotibial angle improved from a mean of −3.22° ± 9.47° before surgery to a mean of 5.16° ± 3.14° at the final follow‐up (P = 0.006). At the time of final follow‐up, no patient required revision and manipulation under anesthesia following the index arthroplasty. No radiolucencies or migration were observed in association with the knee prostheses. No displacement of the screw and rectangular spiked washer was found. There were no clinical complications. No patient reported subjective instability of the knee. Upon physical examination, no patient was found to have laxity in the coronal plane in either 30° of flexion or full extension.ConclusionsThe screw and rectangular spiked washer is a simple and effective method for treating MCL sufficiency in TKA, and a study with a larger cohort and extended follow‐up is requisite to claim its role in preventing coronal instability and component failure.

Is it Possible to Treat Insert Dislocation With a Fixed Insert Tibial Component After Primary Oxford Phase 3 Mobile Unicompartmental Knee Arthroplasty?

Background: The aim of this study was to investigate the clinical and radiologic outcomes of patients who underwent the revision surgery of tibial component replacement using fix-insert in the cases of Oxford phase 3 medial unicompartmental knee arthroplasty with insert dislocation after initial insert replacement. Materials and Methods: Nine patients who experienced insert dislocation after insert replacement and who underwent partial replacement revision (tibial component revision) were included in this study. Demographic data and complications of these patients were evaluated. Clinical outcomes were determined through Knee Society Score and Functional Knee Society Score. Results: Insert redislocation happened in 11 of 17 patients whose insert was already replaced after initial insert dislocation. Among 11 patients, 2 patients underwent primer and revision total knee replacement revision surgery due to gap inequality and medial collateral ligament deficiency. In the other 9 patients, partial tibal component revision was performed. The mean follow-up time for the patients was 44.4 (21 to 76) months. The mean Knee Society Score/Functional Knee Society Score scores were 80.1 (72 to 95)/78.6 (70 to 90) and 79.5 (72 to 90)/77.5 (68 to 90) at the final follow-up after partial revision and before the insert dislocation, respectively. There was no decline in clinical scores and no revision was required in the mid-term follow-up. Conclusions: In this study, we found that there was no worsening in the clinical scores of the patients in the mid-term and no revision was required following the treatment of redislocation through tibial component revision. It was concluded that partial revision treatment with a fixed insert tibial component in the case of insert redislocation does not increase morbidity and could be an ideal treatment option. However, this conclusion should be further supported by multicenter studies along with the high number of cases. Level of Evidence: Level IV—retrospective case-control study.

Biomechanical comparison of knotted and knotless stabilization techniques of the tarsal medial collateral ligament in cats: A cadaveric study.

To compare mechanical properties of intact feline medial collateral ligaments and three techniques for treatment of feline medial tarsal instability. Controlled laboratory study. Forty-eight normal, adult feline tarsi. Three repairs were tested: a bone tunnel with polypropylene (PP) suture, a bone tunnel with polyethylene (PE) cord, and a knotless anchor technique with PE cord. A cyclic (6-N preload; 5-N amplitude; 2-Hz frequency) tensile test (600 cycles) was performed on feline tarsi with either the long or the short medial tarsal ligament intact, with each reconstruction technique followed by a single-cycle load-to-failure test (0.5 mm/s) with a failure point at 2 mm of displacement. Total elongation, peak-to-peak elongation, stiffness, and maximum load to failure point were compared with the intact condition. No differences in stiffness, total elongation, or peak-to-peak elongation were found between specimens repaired with the knotless technique and intact controls (P > .04), whereas tarsi repaired with the tunnel technique and PP were weaker (P < .008). Total and conditioning elongation were greater after tunnel reconstruction with PP than after knotless reconstruction (P = .005). Mean load to 2 mm of displacement tended (P = .03) to be higher after knotless than after knotted PP repairs and did not differ (P = .47) between tarsi repaired with the tunnel or anchor repairs with PE. The mechanical properties of intact tarsi were superior to those of tarsi repaired with tunnel techniques and PP but were similar to those of tarsi repaired with knotless techniques with PE. Feline tarsal stabilization with the knotless technique for tarsal medial collateral ligament insufficiency may reduce the requirement for or duration of postoperative coaptation.

Radiographic Predictors of Medial Collateral Ligament Injury and Stability of the Elbow.

Background:It has been postulated that injury to the medial collateral ligament (MCL) of the elbow is rare in cases of elbow fracture-dislocation, and if the MCL is torn, it does not require surgical repair. Elbow fracture-dislocations with MCL insufficiency are associated with recurrent instability, secondary surgery, and the development of posttraumatic arthritis. With the current study, our aim was to investigate whether evidence of an MCL attachment-site fracture on a radiograph or computed tomography (CT) scan is predictive of MCL insufficiency, the need for MCL repair, and postoperative instability.Methods:This retrospective study included 219 patients (median age of 50 years; 53% female) with elbow fracture-dislocations treated at 2 Level-I trauma centers during the period of 2005 to 2016. Patients were followed for a median of 6.3 years to determine postoperative stability. Operative notes and radiology reports were reviewed to confirm MCL insufficiency and periarticular fractures. Radiographs and CT scans were analyzed by a musculoskeletal fellowship-trained emergency radiologist and a board-certified upper-extremity orthopaedic surgeon.Results:Of the 33 patients with confirmed fractures at an MCL attachment site, 26 (79%) had MCL insufficiency, whereas of the 186 patients without fracture at an MCL attachment site, only 17 (9%) had MCL insufficiency. Of the 6 patients with an attachment-site fracture and MCL insufficiency who did not undergo initial MCL repair, 5 required reoperation. Of the 7 patients without an attachment-site fracture and with MCL insufficiency who did not undergo initial MCL repair, only 1 required reoperation.Conclusions:Fractures involving an MCL attachment site, regardless of their size, help to predict MCL insufficiency. These fractures can be visualized using initial radiographs and CT scans that are routinely obtained. Additional research is required to assess these findings. Our findings further suggest that repairing an MCL-complex injury in cases of fracture-dislocation in which the fracture has occurred at an MCL attachment site may improve elbow stability and decrease the likelihood of requiring reoperation.Level of Evidence:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial Collateral Ligament Deficiency of the Elbow Joint: A Computational Approach.

Computational elbow joint models, capable of simulating medial collateral ligament deficiency, can be extremely valuable tools for surgical planning and refinement of therapeutic strategies. The objective of this study was to investigate the effects of varying levels of medial collateral ligament deficiency on elbow joint stability using subject-specific computational models. Two elbow joint models were placed at the pronated forearm position and passively flexed by applying a vertical downward motion on humeral head. The models included three-dimensional bone geometries, multiple ligament bundles wrapped around the joint, and the discretized cartilage representation. Four different ligament conditions were simulated: All intact ligaments, isolated medial collateral ligament (MCL) anterior bundle deficiency, isolated MCL posterior bundle deficiency, and complete MCL deficiency. Minimal kinematic differences were observed for isolated anterior and posterior bundle deficient elbows. However, sectioning the entire MCL resulted in significant kinematic differences and induced substantial elbow instability. Joint contact areas were nearly similar for the intact and isolated posterior bundle deficiency. Minor differences were observed for the isolated anterior bundle deficiency, and major differences were observed for the entire MCL deficiency. Complete elbow dislocations were not observed for any ligament deficiency level. As expected, during isolated anterior bundle deficiency, the remaining posterior bundle experiences higher load and vice versa. Overall, the results indicate that either MCL anterior or posterior bundle can provide anterior elbow stability, but the anterior bundle has a somewhat bigger influence on joint kinematics and contact characteristics than posterior one. A study with a larger sample size could help to strengthen the conclusion and statistical significant.

Elbow Medial Ulnar Collateral Ligament chronic isolated insufficiency: anatomical M-UCL reconstruction technique and clinical experience in a mid-term follow-up.

This study aims to clinically evaluate, at mid-term follow-up, a group of patients treated by the senior author in the last 6years with our anatomical double-bundle reconstruction surgical technique for the medial ulnar collateral ligament (M-UCL) insufficiency. In this study, we included only patients affected by chronic valgus elbow instability, diagnosed with an accurate clinical evaluation combined with an MRI, without associated fractures that had been surgically treated in the past and without additional instability detected during the first checkup and in the preoperative evaluation under anesthesia. The nine patients enrolled were operated by the senior author between 2011 and 2014 (from 16 to 49years old at surgery, all amateur sportsmen). The average follow-up is 4years (47.6months). The values of the range of movement were recorded and compared. Pain assessment was performed using the VAS scoring system. The recovery of daily activities was evaluated through the validated MEPS and Quick-DASH score scales. All patients underwent an X-ray in two standard projections and a preoperative and follow-up MRI. The recovery of the range of motion was complete in six cases. The remaining three patients had minor loss of extension. None of the patients reported flexion deficits nor pronation-supination at follow-up. All patients achieved subjectively perceived stability and clinically objectified stability at follow-up. Five patients referred a total lack of pain at follow-up. Seven patients achieved full marks in the Mayo Elbow Performance Score and an excellent improvement in the Quick-DASH score. Excellent functional results indicate that M-UCL isolated reconstruction with autologous hamstrings described in this study is a reliable and replicable technique with a reduced incidence of complications. Resuming sports is consistently successful in our patients.

Managing Superficial Distal Medial Collateral Ligament Insufficiency in Primary Total Knee Arthroplasty Using Bone Staples.

Superficial medial collateral ligament (MCL) injury is an occasional intraoperative complication during total knee arthroplasty (TKA) that can lead to failure. Although previous studies have recommended complex repair or conversion to a constrained implant, the authors evaluated results of superficial distal MCL reapproximation using bone staples. Records of 31 patients who underwent staple reapproximation for superficial MCL avulsion from the tibial attachment during primary TKA from 2005 to 2015 were reviewed. They were compared with 685 patients who underwent uncomplicated TKA (primary control) and 18 who underwent revision TKA for instability (secondary control). Subjective knee instability was assessed with a patient questionnaire, and other end points included revision for instability or stiffness and manipulations under anesthesia. The authors prospectively collected Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale satisfaction scores. The mean follow-up was 2.6 years. No patients treated with staple repair required revision for instability, whereas two patients were revised in the primary control. Subjective instability was reported in 19.2% of staple repair patients compared with 24.2 and 46.2% of patients in the primary and secondary controls. The mean KOOS for the staple group was 71.7 points, 77.3 for the primary control, and 49.3 for the secondary. KOOSs for the staple group were 5.6 points lower than the primary control, but 22.4 points higher than the secondary. Staple reapproximation is a simple and effective method for repairing the superficial distal MCL in primary TKA. The rate of instability and functional outcomes was comparable to uncomplicated primary TKA.

Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee.

Distal femoral varus osteotomy is a well-described treatment option for patients with valgus malalignment associated with a variety of underlying conditions. This procedure may be the definitive treatment option in active patients with isolated lateral compartment osteoarthritis or posttraumatic arthritis. It may be a useful concomitant procedure in young patients with lateral meniscus deficiency, focal chondral defects, chronic medial collateral ligament insufficiency, and/or patellofemoral instability. Distal femoral varus osteotomy can be performed with medial closing wedge or lateral opening wedge techniques. Variable outcomes and complication rates have been reported. A framework for the use of distal femoral varus osteotomy can aid the orthopaedic surgeon in the evaluation and treatment of patients with symptomatic valgus malalignment.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle

Background: Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments. Hypothesis: Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries. Study Design: Case series; Level of evidence, 4. Methods: Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated. Results: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation. Conclusion: MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.

Paper #45 - Kinematics of the ulna with medial ulnar collateral ligament insufficiency

Paper #45 - Kinematics of the ulna with medial ulnar collateral ligament insufficiency

Can we use the ipsilateral Hamstrings for ACL Reconstruction in case of medial collateral ligament insufficiency?

Aims and Objectives:Semitendinosus and gracilis muscles (hamstring muscles) are frequently harvested autologous tendon grafts of the knee e.g. for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these muscles in case of insufficiency of the medial collateral ligament (MCL). Hypotheses: First, both the semitendinosus and the gracilis muscles can actively stabilize the joint against valgus stress in the medial collateral unstable knee. Second, this stabilizing influence of these muscles decreases with increasing flexion angleMeterials and Methods:Kinematics were examined in ten fresh-frozen human cadaveric knees using a robotic/UFS testing system and an optical tracking system. The knee kinematics under 5 Nm and 10 Nm valgus stress were determined in the a) MCL intact and b) MCL deficient knee in different flexion angles, respectively using the following simulated muscle loads: 1) 0 N (Idle), 2) 200 N semitendinosus load (ST) and 3) 280 N combined semitendinosus and gracilis load (STGT).Results:Cutting the MCL increased valgus angle under all tested conditions and angles in contrast to the MCL intact knee by 4.3-8.1 degrees for 5 Nm, 6.5-11.9 degrees for 10 Nm valgus torque; P<.01; RM-ANOVA). Applied 200 N simulated ST load reduced the valgus angle significantly in 0°, 10°, 20° and 30° of flexion under 5 Nm and 10 Nm (P< .05) valgus stress. In 0°, 10° and 20° these values were close to the MCL intact joint under the respective torque (both P >.05). The combined 280 N simulated STGT load reduced significantly valgus angle in 0°, 10° and 20° of flexion under 5 Nm and 10 Nm of valgus stress (P< .05) to values near the intact joint (5 Nm: 0°, 10°; 10 Nm: 0°, 10°, 20° - P >.05). In 60° and 90° of flexion ST and STGT loads could not decrease resulting valgus angle of the MCL deficient knee (without hamstring load; P>.05 or valgus increase P<.05).Conclusion:In this human cadaveric study semitendinosus and gracilis muscles can successfully stabilize against valgus stress in the MCL insufficient knee in near-to-extension flexion angles. In the valgus-unstable knee, hamstring muscles should be preserved in (multi-) ligament surgery, but also in joint arthroplasty and osteosynthesis if possible.

Valgus Instability of the Elbow Due to Medial Epicondyle Nonunion: Treatment by Fragment Excision and Medial Collateral Ligament Reconstruction.

The medial epicondyle nonunion becomes symptomatic valgus instability with medial elbow pain and joint instability due to dysfunction of the medial collateral ligament (MCL), thus requiring surgical treatment. The purpose of the present study is to report the clinical result of the fragment excision and ligament reconstruction by free tendon graft in the treatment of symptomatic medial epicondyle nonunion. A retrospective study of five consecutive patients was performed. All five patients had signs and symptoms of valgus instability of the elbow. The mean period of nonunion was 25 years, and their injuries progressed asymptomatically until symptoms developed in adulthood after a second injury. All patients were treated by fragment excision and MCL reconstruction. At the final follow-up, no patients exhibited pain or instability. The mean joint range of motion was 0o of extension and 138o of flexion, with an MEPS of 100 points in all patients. By ligament reconstruction for MCL insufficiency and removing the bone fragments avoided irritation by the bone fragments, pain and instability disappeared, good range of motion was restored, and excellent outcomes were achieved in all patients. We believe that fragment excision and MCL reconstruction should be considered as the treatment option for symptomatic medial epicondyle nonunion of the humerus.

Should the Ipsilateral Hamstrings Be Used for Anterior Cruciate Ligament Reconstruction in the Case of Medial Collateral Ligament Insufficiency? Biomechanical Investigation Regarding Dynamic Stabilization of the Medial Compartment by the Hamstring Muscles

Background: Semitendinosus and gracilis muscles are frequently harvested for autologous tendon grafts for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these hamstring muscles in cases of insufficiency of the medial collateral ligament (MCL). Hypotheses: First, both the semitendinosus and gracilis muscles can actively stabilize the joint against valgus moments in the MCL-deficient knee. Second, the stabilizing influence of these muscles decreases with an increasing knee flexion angle. Study Design: Controlled laboratory study. Methods: The kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force moment sensor system and an optical tracking system. The knee kinematics under 5- and 10-N·m valgus moments were determined in the different flexion angles of the (1) MCL-intact and (2) MCL-deficient knee using the following simulated muscle loads: (1) 0-N (idle) load, (2) 200-N semitendinosus (ST) load, and (3) 280-N (200/80-N) combined semitendinosus/gracilis (STGT) load. Results: Cutting the MCL increased the valgus angle under all tested conditions and angles compared with the MCL-intact knee by 4.3° to 8.1° for the 5-N·m valgus moment and 6.5° to 11.9° for the 10-N·m valgus moment (P < .01). The applied 200-N simulated ST load reduced the valgus angle significantly at 0°, 10°, 20°, and 30° of flexion under 5- and 10-N·m valgus moments (P < .05). At 0°, 10°, and 20° of flexion, these values were close to those for the MCL-intact joint under the respective moments (both P > .05). The combined 280-N simulated STGT load significantly reduced the valgus angle in 0°, 10°, and 20° of flexion under 5- and 10-N·m valgus moments (P < .05) to values near those for the intact joint (5 N·m: 0°, 10°; 10 N·m: 0°, 10°, 20°; P > .05). In 60° and 90° of flexion, ST and STGT loads did not decrease the resulting valgus angle of the MCL-deficient knee without hamstring loads (P > .05 vs deficient; P = .0001 vs intact). Conclusion: In this human cadaveric study, semitendinosus and gracilis muscles successfully stabilize valgus moments applied to the MCL-insufficient knee when the knee is near extension. Clinical Relevance: In the valgus-unstable knee, these data suggest that the hamstring muscles should be preserved in (multi-) ligament surgery when possible.