Proximal Medial Collateral Ligament Research Articles

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 Our preliminary unpublished data with 49 patients treated with this technique and a variety of concomitant ligamentous injury with average follow-up of 1.7 years showed no MCL repair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.

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.

Extracorporale shockwavetherapie bij een calcificatie van het mediale collaterale knieligament: een casus met literatuurnazicht

Extracorporeal shock wave therapy as a treatment for medial collateral knee ligament calcification: case presentation and overview of the literature Background Calcification of the medial collateral ligament is an uncommon cause of medial knee pain. In the few case reports that have been written, in multiple cases various conservative treatments have been assessed, often with an unsatisfactory result, leading to the excision of the toothpaste-like calcification. The conservative treatment consists of a short period of ice, analgesics or anti-inflammatory drugs, physiotherapy, a local corticosteroid injection or ultrasound-guided lavage. Case presentation A 40-year-old man with recurring medial knee pain since 2 years was diagnosed with medial collateral ligament calcification of the right knee. The pain was located near the medial epicondyle of the femur. The range of motion was maximal with painful knee flexion and moderate tenderness at the proximal medial collateral ligament. The pain started after a bicycle crash and the diagnosis was made by means of an MRI. Initially, the pain briefly improved after a local corticosteroid injection and physiotherapy, but reoccurred during running. The subsequent physical examination and ultrasound confirmed the diagnosis. The treatment consisted of a combination of physiotherapy and extracorporeal shock wave therapy, performed twice with an interval of 71 days. The follow-up after 5 months revealed that the patient had regained optimal knee function and was pain free at rest and during running. Conclusion Symptomatic medial collateral ligament calcification is a rarely diagnosed condition, mostly treated surgically without adequate conservative therapy. This case report suggests that conservative therapy consisting of physiotherapy and extracorporeal shock wave therapy can be successful in treating medial collateral ligament calcification.

Arthroscopic Primary Medial Collateral Ligament Repair With Suture Anchor

A medial collateral ligament (MCL) tear is common in cases of isolated injury or in those combined with anterior cruciate ligament injury. Although conservative treatment for an MCL tear is popular, some cases result in residual instability. Thus, the treatment approach of grade III MCL injury remains controversial. In this Technical Note, we present the technique of arthroscopic primary MCL repair with suture anchor. With this technique, proximal MCL injuries can be repaired with minimal invasion. This technique improves valgus stability and enables early rehabilitation, including range of motion and weight-bearing exercise.

Treatment of medial-sided injuries in patients with early bicruciate ligament reconstruction for knee dislocation

PurposeIn knee dislocation with bicruciate ligament and medial side injury (KDIIIM), treatment method of medial side injuries is controversial. The purpose of this study was to evaluate the outcomes of non-operative treatment of proximal and midsubstance and operative treatment of distal avulsion medial collateral ligament (MCL) ruptures in patients with early bicruciate reconstruction.MethodsOne-hundred and forty-seven patients with a knee dislocation and bicruciate ligament injury (KDII-KDV) were identified. Sixty-two patients had KDIIIM injury. Of these, 24 patients were excluded and 13 were lost to follow-up. With a minimum of 2 years of follow-up, IKDC2000 (subjective and objective), Lysholm and Tegner scores and stress radiographs were recorded.ResultsTwenty-five patients were available for follow-up: 18 had a proximal or midsubstance grade-III MCL rupture (proximal MCL group) and 7 had a distal MCL avulsion (distal MCL group). In the proximal MCL and distal MCL groups, respectively, median IKDC2000 subjective scores were 80 (range 57–99) and 62 (range 39–87), and median Lysholm scores were 88 (range 57–99) and 75 (range 40–100). The median medial opening (side-to-side difference) was 2.4 mm (range 0.1–9.2) in the proximal MCL group and 2.5 mm (range 0.2–4.8) in the distal MCL group.ConclusionWe found acceptable recorded outcomes in patients who underwent non-operative treatment of proximal and midsubstance grade-III MCL rupture and operative treatment of distal MCL avulsion with early bicruciate ligament reconstruction.Level of evidenceLevel IV

MRI findings of Stener-like lesion of the knee: A case series with surgical correlation

PurposeTo describe the MRI findings of the “Stener-like” lesion of the knee and its distinction from simple medial collateral ligament (MCL) tear. A “Stener-like” lesion of the superficial medial collateral ligament is a tear involving the distal fibers, where the torn fibers become displaced superficial to the pes anserinus fibers, a displacement which can prevent healing. MethodsNine cases of Stener-like lesion were prospectively diagnosed on MRI. Retrospective, IRB-approved, HIPAA-compliant chart review was performed to determine correlation of surgical and MRI findings. Seven cases were surgically confirmed and are included in the series. ResultsMRI is useful in making the diagnosis of Stener-like lesions and prompting the surgeon to explore the distal MCL. Coronal MRI shows variable proximal retraction of the torn ligament. It has a lax contour and abuts the pes anserinus. The proximity of the torn ligament end to the pes can result in misdiagnosis of a partial tear. Axial images are useful to confirm position of the ligament superficial to the pes. All cases had associated tear of the deep MCL fibers, as well as sprains of the proximal superficial MCL. ConclusionsIt is important to recognize the Stener-like lesion because this lesion is usually managed surgically, while most MCL tears are managed conservatively. The presence of injury to the proximal MCL is usually present, and may be a distractor from the distal injury. Care must be taken to include the distal attachment of the sMCL on coronal MRI images.

THE USE OF SERIAL PLATELET RICH PLASMA INJECTIONS WITH EARLY REHABILITATION TO EXPEDITE GRADE III MEDIAL COLLATERAL LIGAMENT INJURY IN A PROFESSIONAL ATHLETE: A CASE REPORT

Medial collateral ligament (MCL) injuries are one of the most commonly treated knee pathologies in sports medicine. The MCL serves as the primary restraint to valgus force. The large majority of these injuries do not require surgical intervention. A 30-year-old professional wrestling athlete presented to the clinic with acute complaints of right medial knee pain resulting from a traumatic valgus force. Physical exam revealed Grade 3 MCL injury. Magnetic resonance imaging confirmed clinical diagnosis of a Grade 3 proximal MCL tear. This athlete had sustained a prior grade 3 ACL injury with Grade 3 distal MCL injury which required surgery to reconstruct the ACL and repair the MCL 13 months prior, in November of 2015. The subject was successfully treated with a series of three sequential Leukocyte Rich Platelet Rich Plasma (LR-PRP) Injections spaced evenly one week apart in addition to an early physical therapy regimen. The total treatment time was cut down from an expected 35-49 days to 31 days. When paired with the appropriate rehabilitation treatment progression, the use of LR-PRP injections in the treatment of an isolated MCL tear was beneficial for this subject. The results of this case report indicate that the use of LR-PRP and early rehabilitation shows promise in treating an acute grade 3 MCL injury. Future research utilizing randomized controlled trials are needed. Case Report, 4.

Outcomes Following ACL and Grade III MCL Injuries

Objectives:Complete disruptions of the medial collateral ligament (MCL) are rare, but do occur with anterior cruciate ligament (ACL) tears. Complete ACL/MCL injuries may be managed with ACL reconstruction and either conservative or operative treatment of the MCL. MCL tear location has also been associated with outcome. We hypothesized that outcomes would be best with acute surgery and worse with proximal MCL tears.We also hypothesized that operative management of MCL injuries would not influence outcome.Methods:Patients enrolled in a multicenter prospective longitudinal cohort who underwent unilateral primary ACL reconstruction between 2002-2008 and who had 2-year follow-up were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or non-operatively were identified. Concurrent injuries (to meniscus or articular cartilage) and subsequent surgeries were documented. Comparisons of surgical chronicity (before and after 30 days from injury) and MCL tear location (femoral or tibial) were performed. Patient reported outcomes (KOOS, IKDC and Marx activity scores) were measured at the time of ACL reconstruction and at 2-year follow-up.Results:Initially, 3028 patients were identified to have undergone primary ACL reconstruction in the cohort during the identified time frame, with 2586 patients completing 2-year follow-up (85%). Complete MCL tears were documented in 1.1% (27/2586) of the cohort: 16 operatively managed patients and 11 conservatively treated MCLs during ACL reconstruction. Concurrent articular pathology was similar between groups. Clinically important differences were seen in baseline KOOS (all subscales) and IKDC scores, with lower scores seen in patients who underwent operative MCL treatment. Reoperation for arthrofibrosis was higher after operative repair of the MCL (19%) versus nonoperative treatment (9%). At 2 years the non-operative MCL cohort maintained significantly better KOOS Sports Rec (88.2 versus 74.4), KOOS QOL (81.3 versus 68.4), and IKDC (87.6 versus 76.0) scores compared to the MCL surgery group. Marx activity scores were equal between groups at the time of study enrollment, however patients who underwent operative MCL management had lower activity scores at 2 years (6.5 versus 10.7). Tibial-sided MCL injuries were associated with worse baseline outcomes compared with femoral-sided MCL injuries in terms of KOOS ADL, Sports Rec, and QOL subscales, but these differences were resolved by 2 years. Surgical chronicity did not influence 2-year outcome.Conclusion:Complete and combined ACL/MCL injuries are rare. Both operative and nonoperative management of MCL tears in our cohort demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was associated with more frequent stiffness, worse patient-reported outcomes and lower activity at 2 years. There may be a subset of patients with severe combined ACL and medial knee injuries that may benefit from operative management, however, that patient population has yet to be defined.

Combined Reconstruction of the Medial Collateral Ligament and Anterior Cruciate Ligament Using Ipsilateral Quadriceps Tendon–Bone and Bone–Patellar Tendon–Bone Autografts

The exclusive autograft choice for medial collateral ligament (MCL) reconstruction that has been described until today is the semitendinosus tendon. However, this has some potential disadvantages in a knee with combined MCL–anterior cruciate ligament (ACL) injury, including weakening of the hamstring's anterior restraining action in an already ACL-injured knee and nonanatomic distal MCL graft insertion when leaving the semitendinosus insertion intact at the pes anserinus during reconstruction. Moreover, because some surgeons prefer to use the hamstring for autologous ACL reconstruction, the contralateral uninjured knee hamstring needs to be harvested as a graft source for the MCL reconstruction if autografts and not allografts are the surgeons' preference. We describe a technique for performing combined reconstruction of the MCL and ACL using ipsilateral quadriceps tendon–bone and bone–patellar tendon–bone autografts. This technique of MCL reconstruction spares the hamstring tendons and benefits from the advantage provided by bone-to-bone healing on the femur with distal and proximal MCL tibial fixation that closely reproduces the native MCL tibia insertion.

MILD TO MODERATE MEDIAL COLLATERAL LIGAMENT (MCL) INJURIES OF THE KNEE: SONOGRAPHIC FINDINGS AND SONOGRAPHIC VALGUS STRESS TEST

The purposes of this study are to describe the sonographic findings of the injured medial collateral ligament (MCL) of the knee, to perform a sonographic valgus stress test, and to correlate these findings in order to advance the proper treatment for these patients. We examined 23 patients with clinical diagnosis of MCL injury. We evaluated proximal and distal MCL thickness, free fluid, and avulsion fractures. In addition, we performed a sonographic valgus stress test in the stress and rest positions. We also examined the knee joint on the same side in 18 sex- and age-matched patients with no history of knee injury as a control. The average thickness of proximal MCL was 6.4 mm (range, 4.2–8.1 mm) in injured MCL and 4.3 mm (range, 3.2–6.2 mm) in normal MCL. The average thickness of distal MCL was 4.4 mm (range, 2.4–6.1 mm) in injured MCL and 3.1 mm (range, 2.1–4.1 mm) in normal MCL. The average joint space width of the injured knee at rest was 6.1 mm (range, 4.0–8.5 mm) and increased to 10.5 mm (range, 7.6–14.0 mm) after stress. The average joint space width of the normal knee at rest was 6.7 mm (range, 5.0–7.7 mm) and increased to 9.6 mm (range, 7.7–10.4 mm) after stress. In conclusion, the combination of the sonographic findings in MCL injury and the real-time sonography valgus stress test can support the clinical diagnosis and pinpoint the exact location of isolated MCL injury, thus advancing the proper treatment of the patient.

Medial Collateral Ligament Avulsion from Both Tibial and Femoral Attachments: A Case Report

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.