Management of medial-sided knee injuries, part 2: posteromedial corner

Tibial inlay reconstruction of the medial collateral ligament using Achilles tendon allograft for the treatment of medial instability of the knee

Although various surgical procedures have been described for the medical collateral ligament (MCL) reconstruction, none can accurately reestablish its original anatomy and orientation. The purpose of this study was to present a technique restoring the anatomy and stability of the medial knee with an Achilles tendon allograft using a tibial inlay technique. The bone block was fixed into a cancellous trough created on the medial surface of the tibia with a cancellous screw and washer, while the tendinous portion was fixed into the femoral insertion site of the superficial MCL with a bioabsorbable interference screw. This technique can successfully reproduce the native anatomy and orientation of the MCL.

Surgical approach to the posteromedial corner: indications, technique, outcomes

Injuries to the medial side of the knee can occur in isolation or in conjunction with multiple other ligaments about the knee. In addition, medial knee injuries can involve isolated injury to the medial collateral ligament or include the posteromedial structures of the knee. Treatment strategies differ greatly depending on injury pattern. In order to select an appropriate treatment strategy, one must accurately diagnose the injury pattern based on clinical examination and the use of appropriate imaging studies. The fundamental basis for diagnosis of a medial sided knee injury stems from understanding the static and dynamic stabilizing structures that compose the medial side of the knee. It is our aim to define the anatomic roles of medial sided structures, their importance in protecting the biomechanical stability of the knee, as well as provide indications and our preferred procedures for surgical management of these complex injuries.

Posterolateral and posteromedial corner injuries of the knee

Posterolateral (PLC) and posteromedial (PMC) corners of the knee represent complex anatomic regions because of intricate soft tissue and osseous relationships in small areas. Concise knowledge of these relationships is necessary before approaching their evaluation at imaging. Magnetic resonance imaging offers an accurate imaging diagnostic tool to establish normal anatomy and diagnose and characterize soft tissue and osseous injury. It is important to carefully evaluate the PLC and PMC structures on magnetic resonance imaging before planned surgical intervention to avoid potential complications resulting from occult injury.

Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments

PURPOSE

To develop an evidence-based algorithm for the treatment of combined complete tears of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL).

METHODS

We performed a systematic review using computerized keyword searches of Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported stratified outcomes data after the treatment of combined complete tears of the ACL and MCL were included. Data on clinical measures of laxity, range of motion, and strength, as well as subjective outcome measures, were summarized.

RESULTS

Five different treatment approaches were reported. Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period.

CONCLUSIONS

ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Arthroscopic posterior cruciate ligament tibial inlay reconstruction: a surgical technique that may influence rehabilitation

CONTEXT

The reconstruction of isolated complete posterior cruciate ligament (PCL) injuries remains a controversial topic. Proponents for reconstruction cite the premature development of arthritis in the medial and patellofemoral compartments as a compelling reason to offer reconstruction. Currently, no consensus exists about which technique should be used to reconstruct the PCL.

TYPE OF STUDY

Surgical technique.

EVIDENCE ACQUISITION

A MEDLINE and PUBMED search was performed using the following combination of keywords for the years 1985-2009: PCL, posterior cruciate ligament, and rehabilitation. The reviewed articles were those that addressed rehabilitation of the PCL after reconstruction and were written in the English language.

RESULTS

This PCL reconstruction technique may be more inherently stable and allow a more progressive rehabilitation program.

CONCLUSION

There are unique features of all-arthroscopic, double-bundle, allograft reconstruction of the PCL that allow a more aggressive approach in PCL reconstruction rehabilitation. The stability afforded by the anatomic press-fit tibial plug and the augmented tibial and augmented femoral fixation are a plus. The anatomic position of the tibial insertion avoids the "killer turn" of the transtibial approach, limiting concerns for graft abrasion with range of motion and resultant elongation. The outside-in method for the femoral tunnels also minimizes the abrasion that can occur at the "critical corner."