Most Injuries to the Medial Collateral Ligament Result From Blows to What Aspect of the Knee?

• Journal List
• Iowa Orthop J
• v.26; 2006
• PMC1888587

Iowa Orthop J. 2006; 26: 77–ninety.

MCL Injuries of the Knee: Current Concepts Review

Abstract

Medial collateral ligament (MCL) injury is one of the most common knee injuries, specially in young athletic patients. Most MCL injuries tin be managed conservatively with good results. All the same, a consummate understanding of human knee beefcake and the involved structures is necessary to make intelligent treatment decisions. Nosotros will review the anatomy and biomechanics of the MCL, classification systems for MCL injuries, and operative and nonoperative treatment for acute and chronic MCL injuries.

INTRODUCTION

The medial collateral ligament (MCL) is one of the nigh normally injured ligamentous structures of the knee joint articulation.^{1 – three} The popularity of sports, specially those involving valgus human knee loading such as ice hockey, skiing, and football, has contributed to the frequent occurrence of MCL injuries.^{3 – 5} The role of prophylactic bracing has been biomechanically and clinically studied, and in the majority of studies was of limited benefit.^{three , 5 , 7} Other preventive measures such as skill training, dominion modifications, proper equipment, and promotion of off-white play have been proposed, but the efficacy of these changes is not known.^{2 , 5 , 8}

The bulk of patients who sustain MCL injuries of varying severity can achieve pre-injury activity level with nonoperative treatment alone.^{9 – 18} The about severe injuries, particularly those with multiple ligament involvement, may require operative repair or augmentation on an acute basis. In addition, surgical reconstruction is indicated for isolated symptomatic chronic MCL laxity. Nosotros will discuss the functional anatomy, clinical evaluation, and treatment of MCL injuries. We will review the original work by James, which nevertheless applies today in understanding the functional anatomy of medial articulatio genus structures, and our approach to the treatment of astute and chronic medial-sided knee injuries. The authors' preferred surgical techniques for ligamentous repair, augmentation, and reconstruction, besides as postoperative care and complications, will be discussed.

Anatomy

The anatomy of the medial side of the knee is complex, beingness composed of three tissue layers and multiple components with interconnections to the joint sheathing, the muscle-tendon units, and the medial meniscus. The ligamentous sleeve spans the entire medial side of the articulatio genus from the medial aspect of the extensor mechanism to the posterior aspect of the knee joint side by side to the posterior cruciate ligament (Figure 1A). The bulk of the basic beefcake has been described by James,^{nineteen – 21} Warren,^{22 , 23} Hughston,²⁴ and others. In item, Figures 1B, ​ 2B, and ​ 3B are from dissections James performed at the Academy of Iowa during the 1970s.

Figure 1A

Layer I is the deep crural fascia which is in continuity with the medial patellar retinaculum and the sartorial fascia. The fascia spans from the patellar tendon anteriorly to the midline of the popliteal fossa posteriorly. (From Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee joint, an anatomic analysis. J Os Articulation Surg Am 1979;61:58, permission granted.)

Effigy 1B

A cadaver dissection reveals the relationship of the medial retinaculum, the foot anserinus tendons, the semimembranosus tendon, and the saphenous nerve.

Effigy 2A

Cross-department anatomy at the level of the joint line is demonstrated. A carve up can be seen merely in front of the superficial MCL. Layer I and II alloy together along a vertical line i-2 cm anterior to the anterior border of the superficial MCL. At the posteromedial corner of the knee, layers Ii and Three merge forming the posterior oblique ligament, which is augmented past the insertion of the semimembranosus insertions. (From Warren LF, Marshall JL. The supporting structures and layers on the medial side of the articulatio genus, an anatomic assay. J Bone Joint Surg Am 1979;61:58, permission granted.)

Figure 2B

A cadaver dissection shows the slit in front of the superficial MCL (two white triangles). The ligament is long and inserts about 5-seven cm below the joint line. The posterior oblique ligament (POL) is clearly shown in continuity with the parallel fibers of the superficial MCL posteriorly.

Effigy 3A

The posteromedial structures of the knee are demonstrated. Note the relationship between the posterior oblique ligament, the meniscus, and the insertions of the semimembranosus tendon. The five insertions of the semimembranosus include the: (1) pars reflexa; (2) straight posteromedial tibial insertion; (3) oblique popliteal ligament insertion; (4) expansion to posterior oblique ligament; and (5) popliteus aponeurosis expansion. (From Sims, WF and Jacobson, KE. The posteromedial corner of the genu: medial-sided injury patterns revisited. Am J Sports Med 2004. 32(two):337-45, permission granted.)

Figure 3B

Insertions of the semimembranosus (A), with the numbers (1, four, 3) respective to the Figure 3a fable, are shown in a cadaver. The medial gastrocnemius musculus is cutting and elevated proximally (B).

The structures that are considered static stabilizers of the medial knee are the superficial MCL, the deep MCL, and the posterior oblique ligament. The superficial MCL is the primary static medial stabilizer of the articulatio genus situated in the 2nd layer, according to Warren and Marshall'due south three-layer concept.²² It is positioned between the superficial sartorial fascia and the deep MCL. Its parallel fibers originate from the center of articulatio genus movement on the medial femoral epicondyle and insert on the medial attribute of the proximal tibia five to seven centimeters (cm) beneath the articulation line, with an average length of 11 cm and an boilerplate width of ane.five cm (Figure 1B). The ligament is deep to the crural and sartorial fascia and superficial to the deep MCL. Between the anterior edge of the superficial MCL and the confluence of the first and second layers lies a vertical split of varying size and shape (Figures 2A, ​ 2B).

The posterior aspect of the ligament has a continuum of oblique fibers referred to as the "posterior oblique ligament" that arises equally a conjoined structure from the second and the tertiary layers forming the posteromedial capsule (Figures 2B, ​ 3A, ​ 3B). Hughston described the beefcake of this structure.²⁴ The posterior oblique ligament arises from the adductor tubercle of the distal femur and has three distal attachments: i) The prominent tibial arm on the edge of the posterior surface of the tibia; 2) the capsular arm which is continuous with the posterior capsule and the proximal part of the oblique popliteal ligament; and 3) the inferior arm which blends with the sheath covering the semimembranosus tendon and continues on to the tibia simply distal to the direct insertion of the semimembranosus tendon. The deep MCL is the thick function of the heart third of the medial capsule, also known as the "middle capsular ligament" (Effigy 2A). It lies in the tertiary and deepest layer, extending from the femur to the mid-portion of the peripheral margin of the medial meniscus and inserting only beneath the tibial articular margin, making meniscofemoral and meniscotibial portions. In a cadaver sectioning study, the superficial MCL limits valgus and external rotation forces. On the other mitt, the deep MCL and the posterior oblique ligament failed to show a significant contribution to stability in the described planes.²³ However, the posterior oblique ligament was believed to assist the dynamic role of the semimembranosus tendon.²⁴

The dynamic stabilizers of the medial side of the knee are the semimembranosus complex, the quadriceps, and the pes anserinus. The semimembranosus tendon terminates in five different insertions on the posteromedial knee: Two bony insertions on the proximal tibia just below the joint line, 1 into the posterior oblique ligament, ane into the oblique popliteal ligament, and one into the popliteal fascia (Figures 3A, ​ 3B). The semimembranosus plays a significant role in the dynamic stability of the medial side of the human knee by tightening the normally lax posterior oblique ligament while posteriorly displacing the posterior horn of the medial meniscus to prevent impingement during knee flexion.²⁵ The quadriceps and pes anserinus have been shown to potentially increase the effective stiffness of the MCL complex of the knee past 164 percent and 108 percent, respectively. Yet, the reaction fourth dimension of those muscles has proved to be far too slow to protect against nearly sports injuries.²⁶

BIOMECHANICS

The biomechanical backdrop of the MCL accept been studied in both human and fauna models. Areas of nigh intense involvement include structural properties of the MCL, failure modes and failure location, furnishings of immobilization, and ligamentous healing.

In cadaver knees, the superficial MCL provided 57 per centum of the restraining valgus moment at five degrees of knee flexion, and provided 78 per centum of the moment at 25 degrees of knee flexion due to decreased contribution from the posterior capsule.²⁷ The ultimate strength of the homo MCL has been shown to be approximately equal to that of the anterior cruciate ligament (ACL).²⁸ When testing different components separately, the maximum load was found to be 534 N for the superficial MCL, 194 N for the deep MCL, and 425 N for the posterior oblique ligament. Failure occurred at a mean elongation of 10.2 mm, seven.i mm, and 12.0 mm respectively.²⁹ The location of maximum strain of the entire medial collateral complex from cadaver studies was plant to exist near the femoral insertion when the genu was in full extension. This correlates well with a few clinical and laboratory findings that suggest the femoral insertion as the almost common location for MCL injury.^{xv , 30 – 34} Even so, when because each component separately, a cadaver report showed that the femoral attachment was the virtually common site of failure for the superficial MCL, just interstitial failure was more common for the deep MCL and the posterior oblique ligament.²⁹ In contrast, operative findings in clinical serial by Sims and O'Donoghue localized the tibial attachment as the nearly mutual injury site for the superficial MCL, and the femoral attachment as the most common injury site for the deep MCL and the posterior oblique ligament.^{25 , 35} A clinical serial by Hughston demonstrated that the tibial insertion was the virtually mutual site of injury for all the components of the MCL complex.³⁶

With connected displacement after MCL rupture, the ACL may likewise tear, producing a more than all-encompassing injury. In 1 study of MCL injuries, Fetto and Marshall reported the incidence of ACL tears to be 20 pct when there is no valgus laxity on clinical test, 53 percent with laxity only in thirty degrees of genu flexion, and 78 percent with valgus laxity in total extension.^ane Therefore, if the knee opens medially in extension, i must suspect that an ACL injury is likely present.

Several studies have shown that immobilization has detrimental effects on the mechanical backdrop of the MCL, such equally disorganization of collagen fibrils, decrease in the structural properties of the bone-ligament- bone circuitous, and resorption of os at ligament insertion sites.³⁷ On the other hand, controlled motion has positive furnishings on healing in both animate being models and clinical settings.^{nine , 20 , 37} Early controlled move has become a part of standard nonoperative treatment protocols in most current series.^{9 , ten , 38 , 39}

In contrast to the ACL, the MCL has shown excellent healing adequacy in both beast and clinical studies.^{39 – 41} Nevertheless, the biomechanical and biochemical properties of the healing MCL fail to return to normal, making upwardly for the deficiency by an increased mass of healing tissue.⁴⁰ Attempts to improve the quality of the healing ligament accept included motion and immobilization, NSAIDS, hyperbaric oxygen, energy application, and growth factors.⁴² From the promising results of brusque half-life growth factors, focus has been placed on gene transfer as a method of delivering growth factors produced by host cells over an extended treatment period.^{43 – 48} Lastly, the likelihood of satisfactory healing decreases with associated cruciate injury, valgus alignment of the genu, or injury to the deeper capsular ligament, the posterior oblique ligament, or oblique popliteal extensions from the semimembranosus.^{twoscore , 41 , 49 – 51}

CLINICAL EVALUATION

The mechanism of injury tin can be obtained either from direct observation of the injury or by conscientious history taking. Valgus stress is the near common mechanism of injury. However, due to the position of the genu and the forcefulness vectors, a combined flexion/valgus/external rotation injury is normally the finish event.^{52 , 53} The vast bulk of MCL injuries are from a direct blow to the outer aspect of the lower thigh or upper leg, although non-contact valgus external rotation injuries are common in skiing.^{51 , 54}

Other important information from the clinical history includes the location of pain, the ability to ambulate later the injury, time and onset of swelling, the sensation of a pop or tear, the presence of deformity, and the immediate site of tenderness.⁵⁵ The absenteeism of swelling may indicate a astringent tear that allows fluid to extravasate into the surrounding tissue exterior the joint. An acute effusion, inside ii hours of injury, indicates hemarthrosis, whereas swelling that appears 12-24 hours afterwards injury usually indicates a synovial effusion. Seventy-half-dozen percent of patients with complete MCL tears could walk into the part unaided without any support, and pain was found to be worse in incomplete tears than complete tears.³⁶

In Hughston's series, the location of edema and tenderness accurately localized the injury site of the superficial collateral ligaments in 64 and 76 percent of cases respectively.³⁶ The exact location of injuries of the deep MCL and the posterior oblique ligament were constitute to be difficult to palpate because of their deep-seated position, but pain and tenderness in this area may at least betoken the presence of injury to these posteromedial structures, including the semimembranosus attachments.²⁵

The all-time time for examination of the genu is immediately after the injury earlier muscle spasm occurs. Unfortunately, many times this opportunity is but bachelor to team physicians nowadays at the time of injury. In those patients with severe muscle spasms, a 24-60 minutes period of immobilization is usually sufficient for relaxation, and test nether anesthesia is rarely necessary.³⁶ While keeping the patient relaxed, a valgus stress test should be performed with the knee in xxx degrees of flexion, and compared to the contralateral human knee equally a control. The examination is then repeated with the knee in 0 degrees of flexion to recruit the function of remaining posteromedial structures. Whatsoever laxity appreciated from the latter test indicates a complete medial-sided injury and should pb the examiner to suspect associated injuries to the secondary restraints such every bit the cruciate ligaments and the posterior capsule (Figure 4).^{i , 27} The caste of joint opening in millimeters and the quality of the cease point both contribute to the overall assessment of the severity of instability.

Figure four

In complete medial-sided knee injuries, the injury completely tears the superficial and deep MCL, besides as the semimembranosus attachments to the femur as shown here. If the knee joint opens in valgus in extension, usually the posterior oblique and the oblique popliteal ligament extensions from the semimembranosus tendon are ruptured, leaving the semimembranosus fastened to the tibia only. These should be repaired at the fourth dimension of surgery. (Modified from Sims, WF and Jacobson, KE. The posteromedial corner of the articulatio genus: medial-sided injury patterns revisited. Am J Sports Med 2004. 32(two):337-45, permission granted.)

In add-on, the examiner must perform a complete exam to rule out associated injuries to the knee. Injuries commonly seen in combination with MCL injuries include bone bruises, ACL tears, lateral collateral ligament (LCL) tears, medial meniscus tears, lateral meniscus tears, and posterior collateral ligament (PCL) tears.⁵⁶ Fetto and Marshall found ACL disruption to be the most common ligamentous damage associated with MCL injuries, specially loftier-grade MCL tears.^ane Concrete examination is the nearly reliable method to diagnose anteromedial rotatory instability, which can occur with or without an associated ACL injury.^{25 , 57} Anteromedial rotatory instability is detected by performing the anterior drawer examination while holding the tibia in external rotation.⁵⁸ Any evidence of anterior subluxation of the medial tibial plateau during a valgus stress test with the knee in thirty degrees of flexion might too indicate the presence of anteromedial rotatory instability.²⁵ Anterior instability should be advisedly evaluated. Laxity with Lachman'southward testing, especially when the end-signal is absent, is a reliable indicator of ACL rupture fifty-fifty in the face of MCL injury.⁵⁹ The pin shift test should exist interpreted vigilantly since loss of medial pivot might crusade false negative results.⁵⁹ As stated earlier, the presence of a hemarthrosis is also suggestive of an associated ACL rupture. Posterior cruciate ligament injuries, meniscus injuries, and bone contusions on the lateral femoral condyle and posterolateral tibia are not unusual and should be ruled out likewise.⁵²

CLASSIFICATION

The American Medical Association (AMA) classification of MCL injuries has acquired confusion and difficulty in comparison of handling results.^{1 , xiii , 60} In 1976, Hughston standardized MCL injury classification, with further clarification in 1994, into ii related systems: The severity system (class I, 2, Three) and the laxity system (grade i+, two+, 3+).⁵¹ Under this combined classification system, form I, a first-degree tear, involves a few fibers resulting in localized tenderness only no instability. Grade Ii, a 2d-degree tear, is a disruption of more than fibers, with more than generalized tenderness but still no instability. Form Three, a third-caste tear, is a complete disruption of the ligament, with resultant instability. Grade III injuries are subdivided according to the extent of laxity as determined by the amount of accented joint separation from valgus stress with the knee in xxx degrees of flexion. Grade one+, 2+, and 3+ laxities bespeak iii-5 mm, 6-10 mm, and more than x mm of accented medial separation respectively. The location of a tear, the presence or absence of a business firm end-betoken, and other modifications have been added to the AMA classification arrangement.^{xv , 53 , 61 , 62}

Fetto and Marshall defined their grade I injuries every bit those without valgus laxity in both 0 and xxx degrees of flexion, course II injuries equally those with valgus laxity in 30 degrees of flexion but stable in 0 degrees of flexion, and grade III every bit those with valgus laxity in both 0 and xxx degrees of flexion.¹ Of annotation, the authors emphasized the importance of performing the examination in 0 degrees of flexion, which is different from in full extension. In full extension, there is recruitment of ACL function that can mask the laxity of the consummate medial-sided injury. In that location is a high incidence of associated ligamentous injuries with ACL injuries in grade III cases using this classification arrangement. We adopt this nomenclature because it documents the instability from loss of all medial-sided structures, which may affect the treatment options. Unfortunately, the validity and reliability of whatsoever of the classification systems have not been described in the English literature. As the treatment tendency moves toward conservative treatment for all grades of isolated MCL injuries, involvement in classifying this ligamentous injury has declined.²⁵ Nosotros believe that MCL injuries should, at the minimum, be classified as isolated or combined with other pathologies, which will assistance with treatment planning.

IMAGING STUDIES

The need for knee radiographs after injury should be determined according to the Ottawa knee rules.⁶³ If indicated, anteroposterior, lateral, and merchant views are obtained. Stress x-rays are helpful in adolescents to exclude physeal plate injuries.⁶⁴ Efforts have been made to evaluate laxity using combined stress radiographs and stress machines, but this technique has failed to get common practice, mayhap due to the size and complication of the machine.^{65 , 66}

The function of MRI in the nomenclature and treatment planning of medial-sided knee injuries has been increasing. Hayes et al. classified complex knee injuries into ten types based on the mechanism of injury.⁵² Recognition of these patterns may assist appraise the full extent of knee injuries, particularly those involving the posterolateral and posteromedial corners of the knee. A study by Nakamura et al. showed that the location of the injury in the superficial layer on MRI could assistance predict the effect after conservative treatment of class III MCL lesions combined with ACL injuries.³³ Subsequently vi weeks of immobilization in a knee brace, six out of 17 patients presented with rest valgus laxity on examination under anesthesia and were indicated for a medial collateral advocacy or reconstruction at the fourth dimension of the ACL reconstruction. Five out of the half dozen patients had evidence of injury "over the whole length of the superficial layer."³³ Indelicato recommended either a routine MRI or an arthroscopic report in all patients with laxity >10 mm to diagnose intraarticular injuries, considering a capsular tear might mask a significant effusion. ⁵⁵ The authors' preference is by and large to apply MRI only to rule out any other associated injury. In isolated Fetto and Marshall's course I or II injuries, an MRI is not indicated. In grade III injuries, nosotros recommend MRI evaluation to completely assess the extent of the injury and for preoperative planning.

Acute INJURY: TREATMENT RATIONALE AND NONOPERATIVE TREATMENT

Nonoperative care has been proposed as the mainstay handling for the bulk of isolated MCL injuries regardless of severity. Treatment with early on protected range of move exercises and progressive strengthening has been shown to produce excellent results and a high rate of return to sports.^{9 – eighteen} Withal, the electric current handling recommendations have been confused by the conflicting and overlapping classification schemes. For instance, Hughston's grade III injuries include different degrees of laxity from i+ to 3+, derived from the test of the knee in 30 degrees of flexion.³⁶ In contrast, Fetto and Marshall's course III injuries are unstable in 0 degrees of flexion, indicating failure of all posteromedial structures with or without ACL disruption.¹

From a literature review of successful nonoperative treatment, we take plant that all series claimed that "complete" or "grade III" injuries did not include patients with instability in 0 degrees of flexion, with only two exceptions.^{9 , x , xiii , 16 , 67 , 68} This data has given the impression that nonoperative handling is routinely successful for even the most astringent grade of isolated medial-sided knee injury. Skillful results have been achieved with Fetto and Marshall'south grade 2 or Hughston's grade III injuries, with most reports uniformly supporting nonoperative handling.^{15 , 17 , 18} However, for Fetto and Marshall's grade Iii injuries, Kannus showed that the long-term issue of nonoperative treatment was much worse than class I and Two, with a loftier frequency of persistent medial instability, secondary dysfunction of the ACL, muscle weakness, and post-traumatic osteoarthritis of the injured genu.⁶⁹ This supports the recommendation from Fetto and Marshall for operative treatment of all isolated type 3 injuries based on slightly meliorate results in their small series.

With MRI now able to pinpoint the exact location of injury, treatment decisions are beingness based on the anatomic location of the MCL failure. Operative treatment has been recommended for situations where in that location is injury over the whole length of the superficial layer, or a complete injury of both the superficial and deep MCL from the tibia.^{33 , 70} With the exception of those injuries with laxity in extension, we treat all lesser grades of MCL injuries in a hinged knee brace with weight begetting as tolerated and crutches for initial pain relief. The patient tin can get-go isometric and range of motility exercises immediately. Crutches are discontinued when the patient can walk without limping. Anti-inflammatory medication appears to exist beneficial for soft-tissue healing, but results are notwithstanding inconclusive.⁷¹ For athletes, we recommend the goal-oriented rehabilitation programme proposed by Reider et al. which was shown to facilitate early return to sports while having an acceptable rate of re-injury (Tabular array ane).³⁸ When the athlete is ready to return to practice, use of a hinged caryatid is encouraged initially until the athlete feels completely confident about their articulatio genus. Later associated cruciate ligament injuries accept been ruled out past MRI, we care for those patients with laxity at 0 degrees of flexion conservatively, as previously described. The exception is those patients with valgus knee joint alignment and laxity in 0 degrees of flexion. In those patients, early operative repair should be considered.

Tabular array 1

Goal-oriented rehabilitation program for isolated collateral ligament sprains in athletes³⁸

Initial handling

• Employ ice with compressive wrap for twenty minutes and repeat every 3-four hours for the kickoff 24-48 hours.

• Apply minimally restrictive lateral hinge brace (class 2 or 3 injuries).

• Dispense crutches; allow weight bearing every bit tolerated.

Subsequent treatment

• Begin agile range-of-motion exercises in cold whirlpool at to the lowest degree twice daily.

• Brainstorm straight-leg raises and electrical musculus stimulation (if available).

• Maintain general conditioning with upper body ergometer or pond.

Goal 1: Walking unassisted without a limp

• Discard crutches.

• Proceed range of motion, isometric strengthening, and conditioning exercises.

Goal two: ninety degrees of articulatio genus flexion

• Begin stair climber and cycle ergometer with seat loftier; gradually lower seat.

• Begin isotonic progressive restrictive practise for quadriceps and hamstrings; supplement with isokinetic practise if available.

• Go along range of motion and workout exercises.

Goal Three: Total knee motion

• Begin running and functional do plan.

• For example:

  • Jog ane mile.

  • Five successive 100-1000 sprints at one-half speed.

  • V successive 100-yard sprints at iii-quarters speed.

  • Five successive 100-thousand sprints at full speed.

  • Five zigzag sprints at half speed.

  • Five zigzag sprints at full speed.

• Other agility drills (e.g. cariocas).

• Go along conditioning.

Goal four: Consummate entire running program in ane session

• May return to competition if athlete has minimal hurting, full range of motion, and 90 percent of normal force.

• Continue to use brace for all sports participation for residue of the season.³⁸

ACUTE INJURY: OPERATIVE TREATMENT

Though the majority of isolated medial-sided knee injuries tin be managed nonoperatively with skilful results, surgeons may consider operative interventions in specific situations involving complete ligament disruption. Examples include the presence of intraarticular entrapment of the cease of the ligament, a large bony avulsion, a tibial plateau fracture, a complete tibial side avulsion in athletes, or when anteromedial rotatory instability is present on physical examination (Figure v).^{25 , 70 , 72 – 74} In addition, valgus-aligned knees with complete medial injury likely would benefit from acute repair, since these knees practise not tolerate the valgus laxity well. The authors' summary of operative indications for medial-sided knee injuries is shown in Tabular array ii.

Figure 5

A MRI report in an acute injury reveals complete rupture of the superficial and deep MCL from the tibia. The medial meniscus is displaced medially with entrapment of the distal part of the avulsed ligament underneath it (small pointer). Astringent hemarthrosis is seen. Delight annotation the bone bruise at the lateral aspect of the lateral femoral condyle suggesting a valgus mechanism (large arrow).

Tabular array 2

Summary of surgical indications for medial-sided injuries of the genu

Operations	Surgical Indications
Acute repair	Presence of intraarticular ligamentous entrapment A large bony avulsion Associated tibial plateau fracture MRI finding of complete tibial side avulsion in athletes Presence of AMRI* Presence of valgus instability in 0 degrees of flexion in an underlying valgus knee alignment
Delayed repair	Combined with inductive cruciate or other ligament reconstruction if the examination under anesthesia shows valgus laxity in 0 degrees of flexion
Augmentation	Combined with any repair if local tissue is deficient
Reconstruction	Symptomatic chronic valgus laxity
Distal femoral varus osteotomy	Chronic valgus laxity with valgus bony alignment

Primary repair of the MCL is usually performed within seven to 10 days after the injury. Location of the tear and the quality of the tendon as assessed by MRI or arthroscopic examination help guide surgical planning. ³³ Femoral avulsion of the ligament leaves the best tissue for repair and the ligament can be approximated using suture anchors, staples, or a screw and washer. Yet, repair in this location may lead to the almost problems with postoperative movement considering of capsular adhesions and dysfunction of the extensor machinery.⁷⁵ Astute consummate injuries with avulsion of the superficial and deep components off of the tibia tin can be repaired directly as well. Repair tin can be performed using either suture anchors or staples to secure the ligament back to its anatomic location on the proximal medial tibia after tension has been restored.⁷⁰ Often mid-substance, and occasionally tibial-sided injuries, crave augmentation or an allograft reconstruction due to the quality of the remaining tendon.

SURGICAL TECHNIQUE

Test under anesthesia is performed to completely assess the scope of the injury preoperatively. Arthroscopy is performed to rule out any other associated injuries. In addition, arthroscopy can help determine the site of the deep MCL injury, either in a higher place or below the meniscus (Figure 6). In an acute setting, arthroscopy should be performed quickly and efficiently to minimize fluid extravasation. Alternatively, the surgeon may cull to exercise any extended arthroscopic procedures after the exposure is fabricated, allowing it to serve every bit a channel for the drainage of arthroscopic fluid.

Effigy 6

The arthroscopic flick in a case of complete medial-sided knee injury demonstrates pathologic widening of the medial compartment and tiptop of the meniscus from the medial tibial articular surface indicating a rupture of the meniscotibial ligament. In this case, the loose fibers of the superficial MCL are seen (arrow). With combined valgus stress and probing, we were able to identify the loose function distally and so every bit to localize the site of the injury. Arthroscopy can besides be used in chronic cases to direct the surgeon to the area of laxity below or above the joint.

An incision is made on the medial side of the genu over the suspected site of injury. To expose the unabridged MCL, an incision is fabricated from the medial proximal tibia to the medial femoral epicondyle, curving posteriorly in line with the medial intermuscular septum of the thigh. For isolated repairs either distally or proximally, a more than limited arroyo is used. In the example of combined treatment of acute complete MCL tear and an ACL tear, nosotros accept found exposure of the MCL easier if approached through a split up medial incision as opposed to extending the tibial incision for the ACL reconstruction. Care is necessary to preserve the infrapatellar co-operative of the saphenous nerve if possible.

The sartorial fascia is identified without undermining of the subcutaneous tissue sleeve. The crural and sartorial fascia is incised longitudinally. If dealing with a distal injury, the ruptured ends of the superficial MCL are identified beneath the gracilis and semitendinosus tendons (Figure 8A). Hematoma may exist encountered in this plane and should exist removed to let direct visualization of all the injuries. The deep MCL is identified, and the tear is examined. The opening to the joint created by the tear and any injury to the meniscal attachment is inspected. We tend to utilise Hughston's concept of repairing all of the injured structures in anatomic position.²⁴ The repair should begin from the deepest structure outward. A peripheral tear of the medial meniscus is usually seen (33 percent) and nearly all of these are repairable.⁷⁶ This can exist done using an open up technique under direct visualization. The suture knots should exist placed on the outside aspect of the posterior oblique ligament in order to recreate the dynamic function of the meniscus.⁶¹ A meniscofemoral ligament tear tin can exist directly repaired using sutures lone, or suture anchors if necessary. Suture anchor fixation into the tibial plateau is preferred for the meniscotibial ligament tear (Figures vii, ​ 8B). If information technology is injured, the posterior oblique ligament is repaired by straight suture back to the femur.

Figure seven

The intraoperative fluoroscopic picture show of a combined ACL reconstruction and a medial-sided knee repair is shown. The two anchors are used to concur the meniscus down to the tibia and the staple is for superficial MCL stabilization.

Figure 8A:

The torn end of the superficial and deep MCL is elevated demonstrating the medial joint space and the medial meniscus.

Figure 8B:

2 anchors were placed and sutures were brought through the peripheral part of the meniscus to repair the deep capsular ligament.

Figure 8C:

The torn end of the superficial MCL was secured with a staple. The very distal function of the ligament is sutured to the remaining tissue.

For tibial avulsion injuries, we prefer suture anchor fixation downwards to the tibial plateau just distal to the subchondral os. Repair is completed while the articulatio genus is held in varus and full extension. A gentle valgus examination should not gap open the medial joint space if the repair is adequate. The avulsed superficial MCL ends tin be repaired with anchors, staples, or a screw and washer (Effigy 8C). This can be aided by placing a locking suture into the substance of the torn stop of the ligament that allows either proximal or distal traction to be placed on the ligament as fixation is applied. The semimembranosus portion of the posterior oblique ligament is repaired using interrupted absorbable sutures. If possible, the anterior border of the torn posterior oblique ligament can exist sutured to the posterior border of the repaired MCL in a pants-over-vest manner (Figure 9A–C). Avulsion of medial patellofemoral ligament and fierce of the vastus medialis muscle take been plant in association with proximal injuries of the MCL and should be repaired if identified.⁵⁷

Figure 9a:

Technique of posteromedial plication demonstrated in a example with proximal avulsion of the superficial MCL and the posterior oblique ligament. Point A demonstrates the location for suture fixation of the superficial MCL to restore tension. With the genu in threescore degrees of flexion and the hip externally rotated, the posterior oblique ligament is pulled anteriorly and proximally to point B where information technology is being reattached. (From Hughston, JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the ACL. Results of long-term follow-upward. J Os Joint Surg Am 1994. 76(9):1328-44, permission granted.)

Effigy 9b:

The anterior attribute of the posterior oblique ligament is plicated over the superficial MCL in a pants-over-vest fashion. (From Hughston, JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the ACL. Results of long-term follow-up. J Bone Joint Surg Am 1994. 76(ix):1328-44, permission granted.)

Figure 9c:

The lax capsular arm of the semimembranosus tendon is plicated over the restored posterior oblique ligament. (From Hughston, JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the ACL. Results of long-term follow- upwardly. J Bone Joint Surg Am 1994. 76(nine):1328-44, permission granted.)

If injury to the superficial MCL is extensive, augmentation of the repair may exist required.⁷⁷ We prefer the figure- of-eight reconstruction technique described past Gorin using autologous gracilis tendon.⁷⁸ This construct has two bundles, does non interfere with the original insertion, and requires no tunnels. The augmentation can be performed through the previously described operative approach. The gracilis tendon is harvested using a tendon stripper while keeping the tibial insertion attached. The knee is brought to full extension and the deep limb of the effigy-of-eight is secured with a suture anchor placed in a bony trough at the posterior aspect of the medial epicondyle. The tendon is stabilized at another anchor fixation point just anterior to the femoral footprint. With the knee in 30 degrees of flexion, the superficial limb of the reconstruction is fixed to the tibia with a suture anchor approximately ii cm posterior and deep to the pes anserinus insertion. Finally, the tourniquet is deflated and inspection and control of potential excessive haemorrhage from the inferior medial geniculate avenue and its branches is performed. A compressive dressing is applied postoperatively.

POSTOPERATIVE Care

The patient is kept non-weight bearing for 3 weeks in a long hinged knee brace allowing xxx-90 degrees of motion. At 3 weeks the patient is allowed to do full range of move and weight bearing equally tolerated. Progressive activities are started at about half-dozen weeks and the brace is gradually weaned off.

CHRONIC INJURY

Although rare, chronic valgus instability has been described post-obit MCL injury alone or in combination with ACL tears.^{49 , 77 , 79 – 81} This combination has been plant to seriously compromise joint stability, and patients with this injury are more likely to experience symptoms of giving mode than those with isolated ACL deficiency.^{1 , 57 , 82} Slocum defined "belatedly" or "chronic" equally three months or more after the astute injury.⁸³ By that time, the ligaments have lost their healing potential and the anatomic restoration of the traumatized tissue is no longer possible due to the contracture of the ligament ends and the formation of scar tissue. Multiple reconstruction techniques have been described focusing mainly on reconstruction of the superficial MCL with quadriceps tendon autograft, hamstring autograft, hamstring allograft, or Achilles allograft. ^{77 , 79 , 81} Patients with valgus deformity of the knee should take hip-to-ankle radiographs and may need a distal femur varus-producing osteotomy prior to ligament reconstruction in lodge to move the mechanical axis into slight varus. Persistent valgus malalignment will cause graft stretching and recurrence of the instability if non corrected.^{49 , 84} For chronic medial instability nosotros prefer the technique modified from Toth and Warren'southward clarification, using Achilles allograft for reconstruction of the superficial MCL.⁸⁵

SURGICAL TECHNIQUE

Examination under anesthesia is performed to certificate all deficient structures. Arthroscopy can exist done to rule out and care for intra-articular pathologies if indicated. The surgical exposure is performed using a hockey-stick arroyo as described above. The soft tissue flaps are mobilized with a larger inferior flap, assuasive exposure of the fascia over the MCL. The sartorial/crural fascia is incised and reflected anteriorly and posteriorly. The native superficial MCL is identified and dissected. The soft spot between the posterior aspect of the superficial MCL and the posterior oblique ligament is sharply developed for future possible plication. The center of rotation of the articulatio genus joint is identified using a pin technique. A guide pin is drilled into the medial epicondyle parallel to the joint line along the epicondylar axis. One end of suture is fixed to the tibia at the approximate insertion of the superficial MCL. The other stop is looped over the pin and the knee joint is taken through its range of motion. The length of the suture should not change more than 2 mm if the heart centrality is right. An approximately 10 mm reamer is used to make a tunnel 2.5-3 cm in depth, advisedly avoiding penetration into the intercondylar notch. We take establish allograft bone plugs smaller than 10 mm in diameter to be less reliable and more apt to intermission during preparation and fixation. An Achilles allograft is prepared and then that the calcaneal bone plug can fit into the 10 mm sizer with preservation of the tendon insertion and periosteum on one side. The 10 mm x 10 mm x 25 mm os plug is inserted into the tunnel, either freely or using traction sutures and a Beath pin, and fixed with an interference screw on the cancellous side of the bone plug.

The tendinous part of the graft can exist fixed to the tibia in 2 means. The showtime method, described next, involves drilling a tunnel in the tibia. The soft tissue expanse of the Achilles graft is whip-stitched for 4-half dozen cm with #2 Ticron sutures and so sizing is performed. Using a ten-mm reamer, a tibial tunnel is made approximately five cm distal to the joint line and just posterior to the gracilis insertion. The graft is pre-tensioned, and the human knee is moved through a range of motion several times. A Beath pin is and so inserted freehand into the tunnel aiming about one centimeter lateral to the tibial crest to avert injury to the peroneal nerve. The graft is pulled into the tunnel and fixed with a soft tissue interference screw while the knee is held in 30 degrees of flexion, valgus, and internal rotation. Alternatively, the broad expanse of the Achilles graft is fatigued distally with locking traction sutures. It and then can be fixed in place with 2 staples or with suture anchors at its anatomic location. Again, the leg should be held in varus at 30 degrees of flexion during fixation.

We and so evaluate the posterior oblique ligament. With the knee in 60 degrees of flexion and hip in external rotation, the posterior oblique ligament is advanced anteriorly and proximally. Information technology is so fixed to the adductor tubercle using suture anchors. The sutures are tied when the knee is brought to near-total extension. The inductive edge of the posterior oblique ligament is sutured over the reconstructed MCL in a pants-over-belong way. The wound is closed and a compressive dressing is practical.

POSTOPERATIVE Intendance

Generally, we utilize the same protocols previously described for postoperative care after an astute repair.

COMBINED INJURY

Treatments for combined ACL and MCL injuries are still developing. Early on reconstruction of both the ACL and MCL may atomic number 82 to motility loss postoperatively.⁸⁶ Reconstructing only the medial-sided structures is supported only by limited groups.^{fifty , 57} Many authors recommend ACL reconstruction after a catamenia of rehabilitation to allow the MCL to heal.^{54 , 76 , 87} Surgery is performed subsequently achieving full range of move and adequate force, and after resolution of the knee effusion, which typically occurs approximately six weeks afterward the injury. The caveat to this method is that the severity of the knee injuries is not totally articulate in studies supporting this technique. Such variation in the original injury would definitely bear on the issue. For instance, a knee with course 3+ laxity in 30 degrees of flexion that is stable in extension is unlike from a articulatio genus that opens medially in extension. Therefore, at the time of ACL reconstruction, examination under anesthesia must exist performed to determine the residual laxity to valgus stress. We use a residual divergence between legs of more than 3-four mm with valgus stress at total extension as an indication for MCL reconstruction.^{33 , 76} The techniques of MCL repair, augmentation, and reconstruction are the same as previously described in isolated injuries.

COMPLICATIONS

The well-nigh common complications from the medial-sided knee repair or reconstruction are human knee stiffness and residual laxity.⁶¹ Knee stiffness tin can be associated with the timing of repairs, non-anatomic repairs, and issues with postoperative rehabilitation.⁶¹ Stabilizing the superficial MCL too shut to the joint line tin capture the knee. Residual instability by and large stems from failure to accost all the components of the injury, peculiarly the meniscus and posteromedial structures. Repeated examinations during the diverse stages of repair are important to provide optimal stability. In addition, awareness of the restraining structures for various articulatio genus flexion angles is crucial to correct repair or reconstruction.²⁷ Pellegrini-Stieda lesions are sometimes painful, and if nonoperative treatments fail, a resection with a repair may be required.⁸⁸ In full general, most complications can be avoided using the appropriate surgical and postoperative strategies as previously described.

SUMMARY

MCL and medial-sided genu injuries are nevertheless major bug in the modern era of sports medicine. With advances in imaging techniques and refined grading of injuries, surgical treatment for medial-sided articulatio genus injuries, in one case popularized by Hughston, may take a function in many cases.

Long-term studies of the most severe category of MCL injuries are needed to define the best treatment. Yet, about medial-sided injuries are best treated nonoperatively, with proven smashing success.

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