Medial Collateral Ligament Injuries of the Knee
Dr. (Prof.) Anil Arora
MS (Ortho) DNB (Ortho) Dip SIROT (USA)
FAPOA (Korea), FIGOF (Germany), FJOA (Japan)
Commonwealth Fellow Joint Replacement
(Royal National Orthopaedic Hospital, London, UK)
Senior Knee and Hip Replacement Surgeon
Associate Director
Department of Orthopaedics and Joint Replacement
Max Superspeciality Hospital, Patparganj, Delhi (India)
E-mail : [email protected]
12.2mm
12.6mm
61.2mm
3.2mm
Surgically relevant Anatomy
Relevant Anatomy - Attachment
Femoral – oval
3 mm proximal
and 5 mm posterior
to the medial epicondyle
Tibial –
• Proximal tibial attachment
12.2 mm distal to the joint
• Distal tibial is broad
61.2 mm distal to the tibial joint line;
4
Physical Exam - General
Inspection
Palpation
Range of motion
Strength testing
Special tests
MCL Exam
• Valgus force
• > 5 mm difference
significant
• Flex. 300 – Isolated MCL
• Extension
– Assoc. POL, ACL, PCL
Examination
Increased MJO at 30 of flexion but not at 0 The posterior oblique ligament is
most likely still intact
Medial knee structures are completely
ruptured, there will be no definitive
end point and the anterior cruciate ligament
may be providing a secondary restraint
to the valgus stress Verify this observation with the
Lachman, anterior drawer, and pivot
shif tests and assess the integrity of
the anterior cruciate ligament
Complete injury to the medial structures will
cause increased external rotation at Positive dial test
both 30 and 90 of knee flexion,
Increased MJO at 0 & 30 degree of
knee flexion The MCL and POL both are torn
Grades of tear
3-5 mm
laxity
6-10 mm
laxity
>10 mm
laxity
Stress Radiograph
Isolated injury of superficial medial collateral ligament
Complete medial knee injury (superficial medial collateral ligament,posterior oblique ligament, and deep medial collateral ligament)
Increases in medial joint gapping of 1.7 mm at 0 of knee flexion and 3.2 mm at 20 of knee flexion*
Increases in medial joint gapping of 6.5 mm at 0 of knee flexion and 9.8 mm at 20 of knee flexion*
Why MRI
• Grade and site
• Can show entrapped end of torn ligament into
the joint
• Can show torn distal end lying superficial to
Pes Anserinus, and hence indication for
surgery.
Can we treat Nonoperatively
All grade -I sprains
All grade –II sprains
Some grade –III sprains
What are those grade III tear - Nonoperatively
If the tear is at the proximal attachment and there is no
evidence of other ligamentous damage
Elderly patients who do not expect to return to
vigorous activities or to place great demands
Do I need to put a plaster
No
Brace is optimum
Crutch walking is permitted with toe-touch weight
bearing soon
Full extension is obtained by 6 weeks
Treatment with early Protected ROM Exercises
and Progressive Strengthening >>>>> Excellent
Results and
a high rate of Return to Sports
Reider B, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional
rehabilitation. A five-year follow-up study. Am J Sports Med. 1994;22(4):470–477.
Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial
collateral ligament of the knee in intercollegiate football players. Clin Orthop. 1990;256:174–177.
Pforringer W, Beck N, Smasal V. Conservative therapy of ruptures of the medial collateral ligament of the knee.
Results of a comparative follow-up study. Sportverletz Sportschaden.1993;7(1):3–7.
Petermann J, von Garrel T, Gotzen L. Non-operative treatment of acute medial collateral ligament lesions of the
knee joint. Knee Surg Sports Traumatol Arthrosc. 1993;1(2):93–96.
Success of non-operative treatment
of complete tears of the
medial knee structures relies on an
Intact Anterior Cruciate Ligament
OPERATIVE
Surgical indications
• Presence of intraarticular ligamentous entrapment
• A large bony avulsion
• Associated tibial plateau fracture
• Complete tibial side avulsion
• Presence of valgus instability in 0 degrees of flexion in an
underlying valgus knee alignment
Injury over the whole length
of the superficial layer,
or a complete injury of
both the superficial and deep MCL from the tibia
• Wilson TC, Satterfield WH, Johnson DL. Medial collateral ligament "tibial" injuries: indication for
acute repair. Orthopedics. 2004;27(4):389–393.
• Nakamura N, et al. Acute grade III medial collateral ligament injury of the knee associated with
anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a
treatment regimen. Am J Sports Med. 2003;31(2):261–267.
Operative techniques for fresh injuries
• Direct repair of the superficial MCL & POL
• Primary repair with augmentation
• Advancement of the tibial insertion of the Superficial MCL
• Pes anserinus transfer
• Advancement of the superficial MCL with pes anserinus transfer
Tip 1 : Anchor ligament at Isometric point
Origin –oval and,
on the average, 3 mm proximal and 5
mm posterior to the medial
epicondyle
Insertion – proximal tibial
attachment is located an average of
12.2 mm distal to the tibial joint
• The distal tibial is broad and is 61.2
mm distal to the tibial joint line;
Suture anchor repair
Internal fixation should not be used in areas where normal
gliding of the ligament is required during flexion and
extension.
Neither the screw with toothed washer nor the staple should
be overly tightened or countersunk
Approximating sutures apposing the dissected torn edges of
the ligament should be reinforced with tension sutures of non
absorbable material.
Surgical tips
Surgical tips
The superficial medial collateral ligament is tightened at
30 of knee flexion
The posterior oblique ligament is tightened at
0 degree of knee flexion
Rehabilitation program after Repair
The initial range-of-motion exercises (2 weeks)
Prevent adhesion formation;
Extension is allowed to 0
Avoid both hyperextension and flexion past 90
After the initial two weeks
Knee flexion to a full range of motion
No resistive or repetitive hamstring exercises for
approximately four months after the reconstruction
After the initial six weeks of protected weight-bearing
Closed kinetic- chain exercises
Rehabilitation program after Repair
Once full weight-bearing is permitted at the seven-week
Special attention must be paid to the restoration of
normal gait mechanics
Must observe the gait pattern closely
Ensure that the patient is not employing a quadriceps-
avoidance pattern with a hyperextension thrust at the
knee joint during stance phase.
It is also critical that the patient avoid
Posting the foot of the surgically treated extremity lateral
to the base of support in stance in an attempt to unload
the joint
Illustration-1
• Manoj 24/M
• RTA
• ACL, MCL ruptured
• Depressed # Lat. Tibia
MRI
Treatment
• Tibial fixation of MCL
• Repair of PMC, distal most limb of SMCL
• Elevation of depressed tibial condyle
• Filling of void with bone graft
• Across the knee Ex. Fix
Surgical scar
Postop 3 months
Postop 3 months
Postop 3 months
12 months follow up MRINicely reconstituted MCL
Illustration-2
• Vimal, 31/M
• RTA
• Medial opening on valgus
• MCL avulsion femoral side
MRI
MRI
Treatment
• Anatomical restoration of MCL
• Fixation by staple
• Early mobilization
• Protected weight bearing
• QUAD. Exercises
8 weeks postop
12 weeks postop
12 weeks postop
12 weeks postop
Illustration-3
• Sunil,38/M
• RTA
• Medial joint pain
• Give-way
• Apprehension of fall
• Difficult to walk
Postop X-ray
6 Wks
12 Wks
A square or rectangular pattern is used in the manner of
a mattress suture to secure the tension sutures.
Careful alignment of the tension sutures along the
course of the ligament fibers is necessary
Tension sutures can be tested for functional placement
and isometry during flexion and extension before being
tied definitively.
Surgical tips
Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L.Force measurements on the posterior oblique ligament and superficial medialcollateral ligament proximal and distal divisions to applied loads.
Am J Sports Med. 2009;37:140-8.
Aim of an operative repair or reconstruction of the superficial
medial collateral ligament is to restore the distinct functions of
both divisions by reattaching the two tibial attachments in an
attempt to reproduce the overall function Of the superficial
medial collateral ligament construct.
Goal-oriented rehabilitation program treated conservatively
Initial treatment
• Apply ice with compressive wrap for 20 minutes and repeat every 3-4 hours for the first 24-48 hours.
• Apply minimally restrictive lateral hinge brace (grade II or III injuries).
• Dispense crutches; allow weight bearing as tolerated.
Subsequent treatment
• Begin active range-of-motion exercises in cold whirlpool at least twice daily.
• Begin straight-leg raises and electrical muscle stimulation (if available).
• Maintain general conditioning with upper body ergometer or swimming.
Goal-oriented rehabilitation program treated conservatively
• Goal one: Walking unassisted without a limp
• Goal two: 90 degrees of knee flexion
• Goal Three: Full knee motion
• Goal four: Complete entire running program in one session
Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996;21(2):147–156.
Postop 2 months
Postop 2 months
Postop 3 months
Postop 3 months
Postop 3 months
12 weeks postop
12 weeks postop
Thanks