MCL Injuries of the Knee

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MCL Injuries of the Knee

• Kristopher Aalderink, MD
• Orthopaedic Surgery, Sports Fellow
• August 14, 2008

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Presentation Objectives

• Anatomy Function of the MCL
• Biomechanics of MCL
• Physical Exam Techniques
• Diagnostic Studies
• Types of Injuries
• Treatment Options
• Nonsurgical
• Surgical

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Medial Collateral Ligament (MCL)

• One of the most commonly injured ligaments about
  the knee.
• Common in sports involving valgus knee loading
  (football, ice hockey, skiing)

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Anatomy of the MCL

• Composed of both static dynamic parts.
• Static components
• Superficial MCL (primary stabilizer)
• Deep MCL, a thickening of the medial capsule
• Posterior oblique ligament
• Dynamic components semimembranosis, vastus
  medialis, and pes anserinus.

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Anatomy cont

• Three-layer concept described by Warren
  Marshall
• Layer I
• Deep fascia, Sartorius
• Layer II
• Superficial MCL
• Layer III
• Deep MCL
• Posterior oblique ligament- confluence of layers
  2/3

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MCL Function

• Main function is to resist valgus and external
  rotation forces of the tibia in relation to the
  femur.
• Primary stabilizer to valgus force.
• Secondary stabilizer to anterior translation.

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Basic Biomechanics

• Anterior parallel fibers in constant tension
  throughout flexion, whereas posterior fibers were
  oblique and slackened in flexion .
• MCL is tight in external rotation.
• With knee flexion gt 90 degrees,
  the tibia internally rotates,
  relaxing the anterior
  fibers.
• MCL has 1.5cm of excursion
  during knee
  flexion/extension.

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Biomechanics

• The ultimate strength of the human MCL has been
  shown to be approximately equal to that of the
  anterior cruciate ligament (ACL).
• The location of maximum strain of the MCL from
  cadaver studies was found to be near the femoral
  insertion with the knee in full extension.
• In contrast to the ACL, the MCL has shown
  excellent healing capability in both animal and
  clinical studies.

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History Physical Examination

• Mechanism of injury and the position of the knee
  when it was injured.
• Vast majority from direct blow to lateral
  leg/thigh
• Hughston and colleagues found that 76 of
  athletes with grade III injuries could walk into
  the office unaided by external support.

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Physical Examination cont

• Patellar tenderness, apprehension, and medial
  retinacular tenderness are sought because
  patellar dislocation is associated with valgus
  injuries.
• Hunter and colleagues found a 9 to 21 incidence
  of damage to the extensor mechanism (vastus
  medialis tearing) with medial ligament injury.

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MCL Physical Examination

• The gold standard for medial instability is a
  valgus stress test performed at 30 degrees of
  knee flexion.
• If medial opening at 0 degrees, suspect a
  combined ligamentous injury.
• Always compare to
  contralateral limb!
  
  
  
  

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MCL

• Concomitant ligamentous injuries
• 20 of grade I
• 52 of grade II
• 78 of grade III
• ACL most commonly associated combined ligament
  tear

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MCL Physical Examination

• Proximal MCL tears at the femoral insertion are
  more common than at the distal tibial insertion.
• In general, femoral side injuries tend to heal
  better than tibial side or midsubstance injuries.

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Diagnostic Studies

• A-P, Lateral, Merchant (if indicated)
• Stress views
• MRI r/o associated
  injuries

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Diagnostic Studies
Pellegrini-Stieda lesion Chronic MCL injury
characterized by a bony avulsion with
calcification of femoral insertion of MCL
Physeal injury
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MCL Grading System(Hughston)
Grade Description
I involves a few fibers resulting in localized tenderness but no instability
II disruption of more fibers, with more generalized tenderness but still no instability
III complete disruption of the ligament, with resultant instability
1 3-5 mm
2 6-10 mm
3 gt 10 mm
Laxity determined with knee in 30 degrees of
flexion
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MCL Grading(Fetto Marsh)
Grade Description
1 Stable to valgus stress at 0 30 degrees of knee flexion
2 Laxity at 30 degrees of flexion, stable at 0.
3 Valgus laxity at both 0 30 degrees flexion
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Treatment of Isolated MCL Injury

• Stable to valgus stress in extension
• Non-Surgical Treatment
• Crutches until pain subsides, WBAT
• Quad isometrics and ROM
• Hinged-knee brace
• Edema Control - Ice, Compression, Massage
• /- NSAIDs

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MCL 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 w/ valgus knee alignment
Delayed repair Combined with anterior 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 Osteotomy Chronic valgus laxity with valgus bony alignment
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Entrapped MCL
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Acute Repair Surgical Technique(within 7-10
days)

• Femoral avulsion - ligament can be approximated
  using suture anchors, staples, or a screw and
  washer.
• most problems with postoperative motion because
  of capsular adhesions and dysfunction of the
  extensor mechanism
• Tibial avulsion (superficial and deep components)
  repair can be performed using either suture
  anchors or staples, restore tension
• Mid-substance may require augmentation or
  allograft reconstruction.

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Chronic MCL Repair(gt 3 months)

• Focus mainly on reconstruction of the superficial
  MCL
• Numerous options quadriceps tendon autograft,
  hamstring autograft, hamstring allograft, or
  Achilles allograft
• Associated valgus deformity of the knee
• distal femur varus-producing osteotomy

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Combined ACL MCL Injury

• Problems with loss of motion with early
  reconstruction of both the ACL and MCL
• Many authors recommend ACL reconstruction after a
  period of rehabilitation to allow the MCL to heal
• Delay until full ROM, adequate strength,
  resolution of knee effusion
• Residual valgus laxity post ACL reconstruction ?
  reconstruct MCL

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References

• DeLee DeLee and Drez's Orthopaedic Sports
  Medicine, 2nd ed.
• Derscheid et al, Medial collateral ligament
  injuries in football. Nonoperative management of
  grade I and grade II sprains Am J Sports Med.
  1981 Nov-Dec 9(6) 365-8.
• Hughston JC, Barrett GR Acute anteromedial
  rotatory instability. Long-term results of
  surgical repair. J Bone Joint Surg Am 1983 65
  145-153.
• Hunter SC, Marascalco R, Hughston JC Disruption
  of the vastus medialis obliquus with medial knee
  ligament injuries. Am J Sports Med 1983 11
  427-431.
• Indelicato, Isolated Medial Collateral Ligament
  Injuries in the Knee, J Am Acad Orthop Surg 1995
  3 9-14.

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References

• Iowa Orthopaedic Journal, MCL injuries of the
  knee Current concepts review, Vol. 26, pp 77-90.
• Master Techniques in Orthopaedic Surgery
  Reconstructive Knee Surgery, LWW2nd ed, 2003.
• O'Donoghue DH Reconstruction for medial
  instability of the knee. J Bone Joint Surg Am
  1973 55941-954.
• O'Donoghue DH Treatment of acute ligamentous
  injuries of the knee. Orthop Clin North Am
  1973 4617-645.
• Shelburne et al, ACL-MCL injury nonoperative
  management of MCL tears with ACL reconstruction.
  A preliminary report. Am J Sports Med
  20283-286, 1992.
• Sports Medicine, Core Knowledge in Orthopaedics,
  Miller, Sekiya, 2006.

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