Medial Collateral Ligament Tears Research Articles

Multiple knee ligament tear: Magnetic Resonance imaging diagnosis

The rupture of the anterior cruciate ligament is common during physical activities; however, when associated with a multiple ligament injury, it represents an uncommon condition. The diagnosis of this injury is commonly delayed or missed. Consequently, the incidence of this injury may in fact be higher than reported. We present a case of a 27-year-old man with complete tear of the anterior cruciate ligament and of the medial collateral ligament and partial tear of the posterior cruciate, lateral collateral and patellar ligaments treated surgically.

Clinical Results of Isolated MCL Grade III Injury in Acute and Chronic Setting: Systematic Review and Meta-analysis.

The medial collateral ligament (MCL) is frequently involved in injuries around the knee but is uncommonly treated surgically. There are various techniques to reconstruct the medial side of the knee, which have varying outcomes. The purpose of the present systematic review and meta-analysis is to describe the clinical results of surgical management of acute and chronic isolated grade III MCL injury using various functional scores, such as IKDC, Lysholm, and VAS, and to ascertain complication rates associated with these interventions. A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, and two independent authors (L.F and A.M) conducted a comprehensive search across multiple databases (PubMed, Web of Science, and Scopus). They reviewed each article's title and abstract for studies available until April 2024. The search terms used were "((MCL) OR (Medial collateral ligament)) AND (injuries) AND (treatment)". The full texts of the studies were evaluated when eligibility could not be assessed from the title and abstract. The pooled proportion (percentage) of complications from the three studies reporting data on surgery for the MCL acute stage was 15.3% with 95% CI [6.1% to 24.6%]. No complications were reported in studies reporting surgery in the chronic stage. Marked resolution of pain was observed with the mean VAS Score for pain at the final follow-up after surgery for MCL injury in the acute stage was 0.4 with 95% CI [-0.04 to 0.84]. The mean IKDC score at the final follow-up in the three studies reporting data on surgery for the MCL in the acute stage was 79.39 with 95% CI [67.96 to 90.82], and in the chronic stage, was 85 with 95% CI [83.02 to 86.98]. The mean Lysholm Score at the final follow-up after surgery for MCL injury in the chronic stage was 83.04 with 95% CI [75.24 to 94.84], and in the acute stage was 95 with 95% CI [91.76 to 98.24]. This systematic review found that functional outcomes regarding IKDC and LYSHOLM scores were comparable for surgeries performed in acute and chronic MCL tears. There was a marginally increased risk of complication in surgeries performed for acute MCL tears. Compared to the acute phase, a marked resolution of pain was observed at the final follow-up after surgery for MCL injury. Systematic review; level of evidence, 4..

Early combined arthroscopic and open management of combined ACL and PCL tibial spine avulsion in a knee dislocation: A case report

A 35-year-old man presented with right knee pain following a tree stump landing on his leg two days prior. Evaluation revealed a knee dislocation injury (KD III M) with displaced avulsion fractures of the anterior cruciate ligament and posterior cruciate ligament, with the fragments flipped 180 degrees. Additional injuries identified through preoperative imaging (computer tomography, magnetic resonance imaging) and physical examination included bony medial patellofemoral ligament tear, bony posterolateral corner injury, complete medial collateral ligament tear, and medial/lateral meniscus root bony avulsions. The injury was treated utilizing a single-staged arthroscopic and open ligament repair and reconstruction. Bicruciate avulsion fractures in the setting of a knee dislocation injury is a challenging surgical problem in which arthroscopic management of bicruciate tibial spine injuries can be utilized successfully.

Exploring predictors of medial collateral ligament tears in lateral approach total knee replacement: A retrospective study

BackgroundMedial collateral ligament (MCL) tears are uncommon in total knee replacement (TKR), but they pose significant surgical challenges, affecting recovery and outcomes. This study analyzed 18 (1.3 %) MCL tear cases from 1429 TKR procedures using a lateral subvastus approach. Logistic regression with Lasso regularization was used to assess factors like gender, BMI, and knee alignment. Midsubstance disruptions were the most common. MCL tears were more frequent in females, those with higher BMI, and valgus alignment. The Lasso model achieved an AUC of 0.83 and an F1 score of 0.76. MethodsA retrospective analysis on 1429 TKR cases performed by three experienced surgeons using the Optimotion Implant system and specialized MCL retractors was conducted. The lateral subvastus approach without parapatellar arthrotomy. A hinged knee brace was applied postoperatively and a posterior stabilized insert was used for MCL tears. Demographic data were collected, and a Lasso regression model with data balancing, was employed to identify MCL tear predictors. ResultsAmong the 1429 TKR cases, 18 cases (1.3 %) involved MCL tears. The average age of these patients was 67.3 years (not statistically significant). The average BMI for patients with MCL tears was 36.7, significantly higher than the overall group average of 31.5, suggesting a link between higher BMI and MCL tears. Females were notably more affected, making up 88.9 % of the MCL tear cases compared to 11.1 % of males. Regarding knee alignment, 38.9 % had valgus alignment (p < 0.05), No significant differences were observed in knee flexion or Knee Society Scores (KSS) following MCL tears. ConclusionsGender, BMI, and knee alignment are significant factors influencing the incidence of MCL tears in TKR procedures. The Lasso model effectively identified individuals at higher risk. Preventive measures, including surgeon training and the use of specialized MCL retractors, were implemented. Functional outcomes such as knee flexion and KSS scores did not show significant differences post-MCL tear.

Location of medial collateral ligament tears: introduction to a magnetic resonance imaging-based classification.

Despite established tear grade classifications, there is currently no radiological classification for sMCL tear locations. This study aims to establish a magnetic resonance imaging (MRI) tear location classification system for sMCL tears, to enhance understanding and guide treatment decisions by categorizing tear types. A retrospective search in a single institution's MRI database identified patients with acute, Grade III sMCL tears (< 30days between injury and MRI) from January to December 2022. Non-acute and partial tears were excluded, and three observers assessed tear types based on the proposed sMCL MRI tear location system: type I (proximal 25%), Ib (proximal femoral bony avulsion), II (midsubstance, 25-75%), III (distal 25%), IIIb (distal tibial bony avulsion), IIIs (Stener-like lesion). The interclass correlation coefficient (ICC) was used to assess interrater and intrarater reliability for continuous data; Fleiss and Cohen's kappa assessed interrater and intrarater reliability for categorical data. MRI scans of thirty patients with diagnosed sMCL injuries (53% female, mean age 37 ± 13years, range 16-68years) were included based on inclusion/exclusion criteria. Interrater reliability was excellent (ICC: 0.968, 95% CI, 0.933-0.985), and intrarater reliability was excellent (ICC: 0.938, 95% CI: 0.874-0.970 & 0.900, 95% CI, 0.789-0.952). Type I injuries were most common (60%), followed by type III (33.3%), type II (3.3%), type Ib (3.3%), type IIIb (0.0%), and type IIIs (0.0%). The presented MRI-based sMCL tear location classification provides a reproducible system for grading high-grade sMCL injuries. We propose that this framework will significantly unify tear location understanding and support more informed treatment decisions.

Poster 341: Nonoperative Treatment of MCL Tears in ACL/MCL Injuries Does Not Increase ACL Retear Rates

Objectives: There continues to be controversy regarding the treatment of medial collateral ligament (MCL) tears when torn in conjunction with the anterior cruciate ligament (ACL). There is a push to acutely repair or reconstruct the MCL in this setting due to lower revision rates following the ACL reconstruction (ACLR). However, most nonoperative treatment philosophies are focused on immobilization through bracing instead of the more rigid casting approach. The purpose of this study was to determine if there was a difference in ACL retear rates or postoperative stability between those with ACL/MCL injuries and isolated ACL injuries when the MCL was treated nonoperatively, including rigid casting prior to the ACLR. Methods: Between 1982 and 2022, 6047 patients planning to have an ACLR were enrolled into the study. The population was determined with inclusion criteria of a primary ACLR using a patellar tendon graft with minimum 1-year follow up. Patients were excluded with revision ACLR, lateral side or posterior cruciate ligament involvement, or lacking postoperative KT data. Patients were divided into two groups, isolated ACLR (N = 5670) and ACL/MCL (N = 377). All MCL tears were treated nonoperatively and when indicated, they were casted in 30° of flexion and changed weekly until a solid end point was achieved and patients had the ability to bear full weight on the involved side. Once medial side stability was attained, preoperative rehabilitation commenced and range of motion was normalized before the ACLR. Postoperatively, all patients followed the same accelerated rehabilitation program. The KT manual maximum (MM) difference between knees, in millimeters, was used for analysis. Graft retear rate was determined through subjective surveys sent yearly to each patient after surgery. To reduce confounding bias in the analysis, the ACL/MCL patients were control matched 1:1 to the isolated ACL injury patients based on sex, age, postoperative activity rating, and surgery timing, which led to 304 patients in each group. Results: Prior to matching, both groups had similar mean ages and rates of having postoperative activity levels ≥7, however, the ACL/MCL group showed higher rates of males (69.0%) and subacute surgery (71.9%) compared to the isolated ACLR group (59.7% males and 56.6% subacute surgery). After matching, the mean age for both groups was similar (ACL/MCL: 24.6 years, isolated ACLR: 24.9 years) and they showed identical rates of males, postoperative activity rating ≥7, and subacute surgery at 66.4%, 90.4%, and 73.0%, respectively. The KT MM difference for the ACL/MCL group was not statistically significantly different when compared to the isolated ACLR group (1.8mm vs 1.6mm; p=0.196). The ACL retear rate for the ACL/MCL group was 7.9% compared to 6.6% for the isolated ACLR group, which was not statistically significantly different, p = 0.531. Conclusions: When the MCL is treated nonoperatively, including the use of a cast, before an ACLR, postoperative stability and rates of ACL retears are similar to those with an isolated ACL tear. Due to similar outcomes for both groups, surgeries to the MCL, and thus potential complications that can come with it, can be avoided. We postulate that the lack of differences in laxity and retear rates for the ACL/MCL group may be due to more rigid cast immobilization for the MCL, as opposed to bracing. Further study is needed to evaluate this hypothesis.

Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis.

» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.

Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle.

When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. Level IV.

Utilization of cannulated screw fixation of Jail and TiRobot-assisted percutaneous indirect reduction technique for AO/OTA type 41B2 tibial plateau fracture treatment

PurposeThe present study was designed to investigate the precise procedure and effectiveness of percutaneous minimally invasive fixation assisted by TiRobot in managing AO/OTA type 41B2 tibial plateau fracture to provide an alternative solution for clinical application. MethodsIn total, 10 participants with AO/OTA type 41B2 tibial plateau fractures diagnosed by preoperative imaging examinations were enrolled in this study between May 2019 and May 2022. They were 5 males and 5 females, with an average age of 45.6 ± 11.3 years old (range 27–62 years old). All of them had closed fractures, including 6 cases with anterior cruciate ligament (ACL) tibial insertion avulsion fractures, 1 case with medial collateral ligament (MCL) tear, and 4 cases with a lateral meniscus tear. From injury through surgery, the entire time frame was 4.0 ± 1.5 days (range, 2–7 days). Following indirect percutaneous reduction assisted by TiRobot, the Jail method was used to treat all patients with minimally invasive internal fixation. Patients with ligament or meniscus injurieswere treated with arthroscopic surgery in one stage. The standardized functional exercise was performed postoperatively. The knee function was measured using the Hospital for Special Surgery (HSS) score, and the fracture reduction was assessed through the Rasmussen radiology score. ResultsAll patients were followed up for 12.7 ± 6.8 months (6–24 months).The fracture healing time was 11.8 ± 0.8 weeks (10–13 weeks), and the X-rays revealed satisfactory fracture reduction.The knee joint's Rasmussen score was 17.8 ± 0.4 (in the range of 17–18) a year after the procedure, with 8 patients receiving outstanding ratings and 2 cases receiving satisfactory scores. The HSS score was 93.8 ± 2.3 (range, 89 to 96), of which 10 cases were excellent. The motion range of the kneewas 138.7°±2.7° (range, −5° to 0° to 135°). No adverse effects or serious complications, such as internal fixation failure, postoperative infection, popliteal vascular injury, and common peroneal nerve injury, were observed during the last follow-up visit. ConclusionsThe intelligent assistance and accurate guidance of TiRobot can simplify and standardize procedures of percutaneous minimally invasive fixation in theSchatzker type Ⅲ tibial plateau fracture treatment. This technique increases the precision of indirect percutaneous reduction and screw fixation while minimizing bone grafting.

Prevalence of Knee Pain Pathologies Diagnosed By Musculoskeletal Ultrasound In Nepal Police Hospital

Introduction: One of the most frequent cause of orthopedic consultancy in Nepal Police Hospital is acute and chronic knee pain. The purpose of this study was to demonstrate how musculoskeletal ultrasonography aids in the low-cost identification of knee diseases and using ultrasound to compare with the contra lateral knee can be quite beneficial when developing a treatment plan.&#x0D; Methods: A cross sectional study was conducted on 260 patients with clinically confirmed knee pain. All patients were examined by using Sonasite ultrasound machine with linear probe (7-11MHz). The ultrasound examination of the knee started with examination of anterior aspect, followed by medial aspect, lateral aspect in supine position and then in prone position for examination of posterior aspects. The data were collected, tabulated and statistically analyzed using SPSS11.1. Categorical variables were presented in number and percentage, and continuous variables were presented as mean ± SD.&#x0D; Results: In our study, among the 260 cases there were 164 male patients (63.07%) and 96 females (36.93%) with their age ranged between 25-55 years with the mean age of 40 years. Among 260 cases, 103 patients (39.61%) with knee pain had normal finding and 157 patients (60.39%) had knee pathologies. We found joint effusion (8.91%), quadriceps tendinopathy (3.82%), patellar tendinopathy (1.91%), medial meniscal tear (11.46%), lateral meniscal tear (4.45%), synovial hyperplasia (5.73%), medial collateral ligament tear (10.82%), lateral collateral ligament tear (7%), baker,s cyst(2.54%) and osteophytes(43.31%).&#x0D; Conclusions: An efficient imaging technique that may be used as a screening tool for individuals experiencing knee pain is musculoskeletal ultrasound.

NCPD Tests: Medial Collateral Ligament Tear.

NCPD Tests: Medial Collateral Ligament Tear.

Surgical Treatment of an Unusual Ski Injury: Combined Tibial Fracture With Anterior Cruciate Ligament Avulsion and Segond Lesion

Background: Alpine skiing is considered to be a high-risk sport due to frequent knee injuries and lower limb fractures. The most common lower limb fracture is tibial shaft fracture, while the most common ligament injuries include anterior cruciate ligament (ACL) or medial collateral ligament tears. An injury rarely described in the literature is the association of a bony leg fracture with an ACL injury and Segond fracture. Indications: While the tibial fracture can be managed with intermedullary nailing and proximal ACL tears can be managed with primary repair, the combination of treatments including fixation of the Segond fracture is uncommon. Technique Description: We report combination treatment with nailing for the tibial fracture, primary repair for the ACL avulsion, and primary fixation of Segond fracture. Results: Simultaneous reduction and fixation of the fracture and stabilization of the knee with ACL and anterolateral ligament repair in a single stage resulted in an excellent outcome with complete healing of tibial fracture, ACL repair, and Segond fixation at final follow-up. Discussion/Conclusion: Even if combined leg fracture associated with ipsilateral ACL tear and Segond fracture is a very rare injury, the described technique based on 1-stage fixation of the 3 injuries is a viable option. This surgical technique can be considered a reparative treatment, with the goal of preserving the joint. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Adipose-Derived Stem Cell Injection on a Grade III Medial Collateral Ligament Tear in a Soccer Player: A Case Report

Stem cells are undifferentiated cells that can divide and differentiate into various types of cells. This special ability makes stem cells a hopeful treatment for regenerating damaged tissue and restoring diminished or completely lost function. In this case study, we discuss a 19-year-old soccer player who presented with a Grade III MCL tear on the right knee. Treatment for a Grade III MCL tear is controversial being that both surgical and non-surgical approaches have been effective. However, due to the patient’s sports background, the patient came to our clinic seeking a faster recovery using a non-surgical treatment. After extensive medical examinations, the patient began a treatment based on adipose tissue-derived stem cells injection. Adipose tissue-derived stem cells were harvested and injected into the distal insertion of the superficial MCL and on the deep MCL origin. After 122 days the patient was able to practice full contact sports which is a significant decrease compared to a recent study that averaged surgical recovery time to 181 days. The recovery was supported by an MRI which demonstrated full regeneration of the previously damaged MCL. This case study demonstrates the potential stem cells have in both complementing and replacing surgical treatments for tissue repair. In addition, this case study demonstrates the efficacy of accelerating recovery of MCL tears using stem cells which inspires hope of using stem cells in similar pathologies. Therefore, more clinical trials should be conducted to further expand research on stem cell treatment in regenerative medicine.

MRI Findings Associated With Anterior Cruciate Ligament Tears in National Football League Athletes.

Anterior cruciate ligament (ACL) tears are a high-frequency injury requiring a lengthy recovery in professional American football players. Concomitant pathology associated with ACL tears as identified on magnetic resonance imaging (MRI) is not well understood in these athletes. To describe the MRI findings of concomitant injuries associated with ACL tears among athletes in the National Football League (NFL). Cross-sectional study; Level of evidence, 3. Of 314 ACL injuries in NFL athletes from 2015 through 2019, 191 complete MRI scans from the time of primary ACL injury were identified and reviewed by 2 fellowship-trained musculoskeletal radiologists. Data were collected on ACL tear type and location, as well as presence and location of bone bruises, meniscal tears, articular cartilage pathology, and concomitant ligament pathology. Mechanism data from video review were linked with imaging data to assess association between injury mechanism (contact vs noncontact) and presence of concomitant pathology. Bone bruises were evident in 94.8% of ACL tears in this cohort, most often in the lateral tibial plateau (81%). Meniscal, additional ligamentous, and/or cartilage injury was present in 89% of these knees. Meniscal tears were present in 70% of knees, lateral (59%) more than medial (41%). Additional ligamentous injury was present in 71% of all MRI scans, more often a grade 1/2 sprain (67%) rather than a grade 3 tear (33%), and most often involving the medial collateral ligament (MCL) (57%) and least often the posterior cruciate ligament (10%). Chondral damage was evident in 49% of all MRI scans, with ≥1 full-thickness defect in 25% of all MRI scans, most often lateral. Most (79%) ACL tears did not involve direct contact to the injured lower extremity. Direct contact injuries (21%) were more likely to have a concomitant MCL tear and/or medial patellofemoral ligament injury and less likely to have a medial meniscal tear. ACL tears were rarely isolated injuries in this cohort of professional American football athletes. Bone bruises were almost always present, and additional meniscal, ligamentous, and chondral injuries were also common. MRI findings varied by injury mechanism.

A Single-Centre, Retrospective, Observational Study to Assess Safety and Functional Outcomes of Arthroscopic Meniscal Repair Using Surestitch All Inside Implant.

Introduction The meniscus plays a vital role in maintaining knee stability. It acts as a shock absorber and knee filler. The incidence of meniscal tears is estimated to be 60 per 100,000 people. Due to lack of awareness among patients, only 10% of the meniscus tears were treated through partial or total meniscectomy. Recently, the concept of meniscus preservation surgery has emerged to preserve early degeneration of the knee joint. In the current retrospective study, safety and functional outcomes of arthroscopic meniscal repair surgery using SurestitchAll inside implants (Sironix Arthroscopy Solutions, Healthium Medtech Limited, Bengalaru, India) were assessed. Methods Fifty-two patients who underwent arthroscopic meniscal repair surgery between January 2019 to July 2022 at Epic Hospital in Gujarat, India, were enrolled in the study. Retrospective data including demographics, injury details, surgery details, and post-surgery complications were collected from the medical records of the patients. Then, the patients were followed up telephonically to document safety and functional outcomes using patient-reported instruments such as International Knee Documentation Committee (IKDC) score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity level, and Lysholm knee score. Results The recruited patients had the mean age, height, and weight of 37.56 ± 12.52 years, 167.61 ± 7.28 cm, and 75.87 ± 10.7 kgs, respectively. Seventy-one percent of patients were male and 29% were female. Majority of the patients had the routine of doing mild exercise. During pre-surgery representations, medial meniscal tear was observed in majority of patients. The mean length of the tear was 1.32 ± 0.84 cm. In addition, patients were also diagnosed with anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) tears, and osteochondral defects. Surgeries for meniscal repair were performed using Surestitch All inside implant. In patient-reported outcomes, the mean IKDC, SANE, and Lysholm scores were 81.72 ± 14.23, 94.02 ± 13.79, and 93.32 ± 14.63, respectively. When the mean Tegner scores of pre-injury and post-surgery periods were compared, this resulted in no significant difference (p>0.05) in the activity levels of the patients. Conclusion Based on our findings, arthroscopic meniscal repair with Surestitch All inside meniscal repair implant provides satisfactory and favorable functional outcomes with no remarkable adverse events.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries—Which Is Best? A Systematic Review and Meta-analysis

Background: Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries. Purpose: To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach. Results: In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength. Conclusion: Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

Does proximal versus distal injury location of the medial ulnar collateral ligament of the elbow differentially impact elbow stability? An ultrasound-guided and robot-assisted biomechanical study.

The location (proximal vs. distal) of elbow medial ulnar collateral ligament (MUCL) tears impacts clinical outcomes of nonoperative treatment. The purposes of our study were to (1) determine whether selective releases of the MUCL could be performed under ultrasound (US) guidance without disrupting overlying soft tissues, (2) assess the difference in medial elbow stability for proximal and distal releases of the MUCL using stress US and a robotic testing device, and (3) elucidate the flexion angle that resulted in the greatest amount of medial elbow laxity after MUCL injury. Sixteen paired, fresh-frozen elbow specimens were used. Valgus laxity was evaluated with both US and robotic-assisted measurements before and after selective MUCL releases. A percutaneous US-guided technique was used to perform proximal MUCL releases in 8 elbows and to perform distal MUCL releases in their matched pairs. The robot was used to determine the elbow flexion angle at which the maximum valgus displacement occurred for both proximally and distally released specimens. Open dissection was then performed to assess the accuracy of the percutaneous releases. Percutaneous US-guided releases were successfully performed in 15 of 16 specimens. The proximal release resulted in greater valgus angle displacement (11°±2°) than the distal release (8°±2°) between flexion angles of 30° and 70° (P<.0001 at 30°, P<.0001 at 40°, P=.001 at 50°, P=.005 at 60°, and P=.020 at 70°). Valgus displacement between release locations did not reach the level of statistical significance between 80° and 120° (P=.051 at 80°, P=.131 at 90°, P=.245 at 100°, P=.400 at 110°, and P=.532 at 120°). When we compared the values for the mean increase in US delta gap (stressed - supported state) from before to after MUCL release, the proximally released elbows had larger increases than the distally released elbows (5.0 mm proximal vs. 3.7 mm distal, P=.032). After MUCL release, maximum mean valgus displacement occurred at 49° of flexion. US-guided selective releases of the MUCL can be performed reliably without violating the overlying musculature. Valgus instability is not of greater magnitude for distal releases when compared with proximal releases. This findings suggests there must be alternative factors to explain the difference in clinical prognosis between distal and proximal tears. The observed flexion angle for maximum valgus laxity could have important implications for elbow positioning during US or fluoroscopic stress examination, as well as surgical repair or reconstruction of the MUCL.

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.

Primary Repair of Medial Collateral Ligament Tears With Suture Augmentation

Background: The medial collateral ligament (MCL) is considered to have superior healing and has classically been treated nonoperatively in low-grade MCL injuries. The MCL injury in the setting of concomitant anterior cruciate ligament (ACL) injury is usually treated with a delay of surgery to allow for nonoperative MCL treatment. Recent studies have shown that even with grade II MCL injury there may be residual laxity which may affect place greater strain on an ACL graft in the multi-ligamentous setting and can be corrected for with early primary repair of the MCL which also allows for early definitive treatment of concurrent ipsilateral ligamentous injuries. Indications: All patients are potential candidates given sufficient tissue quality for repair; however, this procedure is preferably performed acutely to avoid scarring, quadriceps strength loss, and allow for early intervention to any concurrent ipsilateral ligamentous knee injury. This technique may be performed on both proximal and distal MCL injuries with the same anchor positioning in either case. Technique Description: The torn superficial and deep MCL are sutured using a Bunnell-type pattern. The superficial proximal MCL is then fixed to its anatomic footprint using a suture anchor preloaded with an internal suture tape augmentation. A second small incision is made over the tibial insertion of the MCL and a passing suture is channeled from the distal to proximal incision under a skin bridge to retrieve the suture tape. The suture tape is then deployed with appropriate tensioning to the anatomic distal insertion point of the superficial MCL using a second suture anchor. Results: There is currently no published data regarding patient outcomes after MCL primary repair with suture augmentation. Our preliminary unpublished data with 49 patients treated with this technique and a variety of concomitant ligamentous injury with average follow-up of 1.7 years showed no MCL repair failures. Four patients experienced more than 10° of flexion range of motion loss, and 3 had residual valgus laxity of grade 1 at 0° and 30° of flexion. Conclusion: Primary MCL repair provides a minimally invasive treatment option for medial laxity, while the suture augmentation allows for early range of motion. Furthermore, this approach avoids delayed definitive surgical intervention of concomitant ligamentous injuries in the setting of combined multi-ligamentous injuries.

Point-Of-Care Ultrasonography for Diagnosis of Medial Collateral Ligament Tears in Acute Knee Trauma; a Diagnostic Accuracy Study

Introduction:The use of point-of-care ultrasonography (POCUS) for identifying medial collateral ligament (MCL) tears has increased in recent years. This study aimed to evaluate the diagnostic accuracy of POCUS in the diagnosis of acute MCL tears of the knee.Methods:This prospective cross-sectional study was performed on patients with suspected MCL tear of the knee in the emergency department (ED). After history taking and primary physical examination, radiographic imaging of the knee was done. If there was no fracture in the knee X-ray, the POCUS examination was done. All of the patients were asked to refer to an orthopedic clinic, 7-10 days after discharge from ED, for Magnetic Resonance Imaging (MRI) evaluation. The second POCUS was done in the orthopedic clinic. Finally, the findings of POCUS and MRI were compared in diagnosing MCL injury.Results:Two hundred and fifty patients with a mean age of 25.05 ± 9.12 years were analyzed (86.8% male). According to the MRI findings, as the gold standard, 55(22.0%) patients had MCL injury. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy of ultrasound in detection of MCL injury, in comparison with MRI were 83.64 (95% CI, 71.20 to 92.23), 94.36% (95% CI, 90.13 to 97.15), 80.70% (95% CI, 69.95 to 88.25), 95.34% (95% CI, 91.83 to 97.38), and 92.00% (95% CI, 87.92 to 95.05), respectively. The area under the receiver operating characteristic (ROC) curve of POCUS was 0.890 (95% CI, 0.844 to 0.926).Conclusion: It seems that POCUS can be applied in screening patients with MCL tears following blunt knee trauma.