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Beel W, Vivacqua T, Willing R, Getgood A. Double-Bundle Medial Collateral Ligament Reconstruction Improves Anteromedial Rotatory Instability. Am J Sports Med 2024:3635465241251463. [PMID: 38828624 DOI: 10.1177/03635465241251463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)-injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. PURPOSE To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL-deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. RESULTS Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR (P < .05). All reconstructions restored VR to the intact state except at 90° of knee flexion (P < .05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position (P < .05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT (P < .05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion (P < .05). CONCLUSION In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. CLINICAL RELEVANCE In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs.
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Affiliation(s)
- Wouter Beel
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Thiago Vivacqua
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Willing
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
- Western's Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
- Western's Bone and Joint Institute, Western University, London, Ontario, Canada
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Beel W, Doughty C, Vivacqua T, Getgood A, Willing R. Effect of a Partial Superficial and Deep Medial Collateral Ligament Injury on Knee Joint Laxity. Am J Sports Med 2024:3635465241251454. [PMID: 38767158 DOI: 10.1177/03635465241251454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Injuries to the medial collateral ligament (MCL), specifically the deep MCL (dMCL) and superficial MCL (sMCL), are both reported to be factors in anteromedial rotatory instability (AMRI); however, a partial sMCL (psMCL) injury is often present, the effect of which on AMRI is unknown. PURPOSE To investigate the effect of a dMCL injury with or without a psMCL injury on knee joint laxity. STUDY DESIGN Controlled laboratory study. METHODS Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. The anterior cruciate ligament (ACL) was cut first and last in protocols 1 and 2, respectively. The dMCL was cut completely, followed by an intermediary psMCL injury state before the sMCL was completely sectioned. Tibiofemoral kinematics were measured at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 4 N·m of external tibial rotation, 4 N·m of internal tibial rotation, and combined 89 N of anterior tibial translation and 4 N·m of external tibial rotation for both anteromedial rotation (AMR) and anteromedial translation. The differences between subsequent states, as well as differences with respect to the intact state, were analyzed. RESULTS In an ACL-intact or -deficient joint, a combined dMCL and psMCL injury increased external tibial rotation and VR compared with the intact state at all angles. A significant increase in AMR was seen in the ACL-intact knee after this combined injury. Cutting the dMCL alone showed lower mean increases in AMR compared with the psMCL injury, which were significant only when the ACL was intact in knee flexion. Moreover, cutting the dMCL had no effect on VR. The ACL was the most important structure in controlling anteromedial translation, followed by the psMCL or dMCL depending on the knee flexion angle. CONCLUSION A dMCL injury alone may produce a small increase in AMRI but not in VR. A combined dMCL and psMCL injury caused an increase in AMRI and VR. CLINICAL RELEVANCE In clinical practice, if an increase in AMRI at 30° and 90° of knee flexion is seen together with some increase in VR, a combined dMCL and psMCL injury should be suspected.
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Affiliation(s)
- Wouter Beel
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Callahan Doughty
- School of Biomedical Engineering, Western University, London, Ontario, Canada
| | - Thiago Vivacqua
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
- Western's Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Ryan Willing
- Western's Bone and Joint Institute, Western University, London, Ontario, Canada
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
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Marcheggiani Muccioli GM, Rinaldi VG, Zaffagnini S. Anterior Cruciate Ligament Over-The-Top Plus Lateral Plasty and Minimally Invasive Double-Bundle Posteromedial Corner Reconstruction. Arthrosc Tech 2024; 13:102957. [PMID: 38835476 PMCID: PMC11144962 DOI: 10.1016/j.eats.2024.102957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
The medial collateral ligament (MCL) and the posteromedial corner (PMC) of the knee are essential structures for maintaining medial knee stability. Chronic MCL instability is infrequent but can necessitate surgical intervention. Various surgical techniques have been described, but they often involve the use of tibial tunnels, which may complicate concurrent ligament reconstructions. This study aims to present a minimally invasive double-bundle PMC reconstruction technique that avoids the use of tibial tunnels. Knee evaluation was performed using standard clinical tests and 1.5-Tesla magnetic resonance imaging. Patients with grade III Hughston MCL injuries were considered for surgery. The technique employs either an autologous semitendinosus graft or a fresh-frozen allograft, usually tibialis anterior, to reconstruct both the superficial MCL and the posterior oblique ligament. The technique described avoids the use of tibial tunnels, preserving tibial bone stock for any future procedures. The graft is secured at the femoral and tibial insertions using bioabsorbable interference screws and titanium staples, respectively. Our minimally invasive double-bundle PMC reconstruction technique offers a feasible and effective solution for patients with chronic medial knee instability. It is particularly beneficial for patients requiring multiple ligament reconstructions, as it avoids tunnel collision and preserves tibial bone stock.
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Affiliation(s)
| | - Vito Gaetano Rinaldi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- DIBINEM, University of Bologna, Bologna, Italy
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Shatrov J, Bonacic Bartolin P, Holthof SR, Ball S, Williams A, Amis AA. A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques. Am J Sports Med 2024; 52:1505-1513. [PMID: 38551132 PMCID: PMC11064462 DOI: 10.1177/03635465241235858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/03/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND There is little evidence of the biomechanical performance of medial collateral ligament (MCL) reconstructions for restoring stability to the MCL-deficient knee regarding valgus, external rotation (ER), and anteromedial rotatory instability (AMRI). HYPOTHESIS A short isometric reconstruction will better restore stability than a longer superficial MCL (sMCL) reconstruction, and an additional deep MCL (dMCL) graft will better control ER and AMRI than single-strand reconstructions. STUDY DESIGN Controlled laboratory study. METHODS Nine cadaveric human knees were tested in a kinematics rig that allowed tibial loading while the knee was flexed-extended 0° to 100°. Optical markers were placed on the femur and tibia and displacements were measured using a stereo camera system. The knee was tested intact, and then after MCL (sMCL + dMCL) transection, and loaded in anterior tibial translation (ATT), ER, varus-valgus, and combined ATT + ER (AMRI loading). Five different isometric MCL reconstructions were tested: isolated long sMCL, a short construct, each with and without dMCL addition, and isolated dMCL reconstruction, using an 8 mm-wide synthetic graft. RESULTS MCL deficiency caused an increase in ER of 4° at 0° of flexion (P = .271) up to 14° at 100° of flexion (P = .002), and valgus laxity increased by 5° to 8° between 0° and 100° of flexion (P < .024 at 0°-90°). ATT did not increase significantly in isolated MCL deficiency (P > .999). All 5 reconstructions restored native stability across the arc of flexion apart from the isolated long sMCL, which demonstrated residual ER instability (P≤ .047 vs other reconstructions). CONCLUSION All tested techniques apart from the isolated long sMCL graft are satisfactory in the context of restoring the valgus, ER, and AMRI stability to the MCL-deficient knee in a cadaveric model. CLINICAL RELEVANCE Contemporary MCL reconstruction techniques fail to control ER and therefore AMRI as they use a long sMCL graft and do not address the dMCL. This study compares 5 MCL reconstruction techniques. Both long and short isometric constructs other than the long sMCL achieved native stability in valgus and ER/AMRI. Double-strand reconstructions (sMCL + dMCL) tended to provide more stability. This study shows which reconstructions demonstrate the best biomechanical performance, informs surgical reconstruction techniques for AMRI, and questions the efficacy of current popular techniques.
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Affiliation(s)
- Jobe Shatrov
- Imperial College London, London, United Kingdom
- Fortius Clinic, London, United Kingdom
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Behrendt P, Robinson JR, Herbst E, Gellhaus F, Raschke MJ, Seekamp A, Herbort M, Kurz B, Kittl C. Isometry of anteromedial reconstructions mimicking the deep medial collateral ligament depends on the femoral insertion. Knee Surg Sports Traumatol Arthrosc 2024; 32:978-986. [PMID: 38431913 DOI: 10.1002/ksa.12111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE This study aimed to investigate the length change patterns of the native deep medial collateral ligament (dMCL) and potential anteromedial reconstructions (AMs) that might be added to a reconstruction of the superficial MCL (sMCL) to better understand the control of anteromedial rotatory instability (AMRI). METHODS Insertion points of the dMCL and potential AM reconstructions were marked with pins (tibial) and eyelets (femoral) in 11 cadaveric knee specimens. Length changes between the pins and eyelets were then tested using threads in a validated kinematics rig with muscle loading of the quadriceps and iliotibial tract. Between 0° and 100° knee flexion, length change pattern of the anterior, middle and posterior part of the dMCL and simulated AM reconstructions were analysed using a rotary encoder. Isometry was tested using the total strain range (TSR). RESULTS The tibiofemoral distance of the anterior dMCL part lengthened with flexion (+12.7% at 100°), whereas the posterior part slackened with flexion (-12.9% at 100°). The middle part behaved almost isometrically (maximum length: +2.8% at 100°). Depending on the femoral position within the sMCL footprint, AM reconstructions resulted in an increase in length as the knee flexed when a more centred position was used, irrespective of the tibial attachment position. Femoral positioning in the posterior aspect of the sMCL footprint exhibited <4% length change and was slightly less tight in flexion (min TSR = 3.6 ± 1.5%), irrespective of the tibial attachment position. CONCLUSION The length change behaviour of potential AM reconstructions in a functionally intact knee is mainly influenced by the position of the femoral attachment, with different tibial attachments having a minimal effect on length change. Surgeons performing AM reconstructions to control AMRI would be advised to choose a femoral graft position in the posterior part of the native sMCL attachment to optimise graft length change behaviour. Given the high frequency of MCL injuries, sufficient restoration of AMRI is essential in isolated and combined ligamentous knee injuries. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Florian Gellhaus
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Andreas Seekamp
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Bodo Kurz
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Willinger L, Runer A, Vieider R, Muench LN, Siebenlist S, Winkler PW. Noninvasive and Reliable Quantification of Anteromedial Rotatory Knee Laxity: A Pilot Study on Healthy Individuals. Am J Sports Med 2024; 52:1229-1237. [PMID: 38506950 PMCID: PMC10986148 DOI: 10.1177/03635465241234263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/18/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND Anteromedial rotatory instability (AMRI) of the knee is a complex and severe condition caused by injury to the anterior cruciate ligament and/or the medial collateral ligament. Clinical studies dealing with AMRI are rare, and objective measurements are nonexistent. PURPOSE/HYPOTHESIS The objectives of this study were, first, to quantify anteromedial rotatory knee laxity in healthy individuals using a noninvasive image analysis software and, second, to assess intra- and interrater reliability and equivalence in measuring anteromedial knee translation (AMT). It was hypothesized that AMT could be reliably quantified using a noninvasive image analysis software. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This prospective proof-of-concept study included healthy individuals aged 16 to 40 years with no history of knee injury or surgery. Three adhesive surface markers were placed on predefined landmarks on the medial side of the knee. Three independent investigators examined anteromedial rotatory knee laxity with an anterior drawer test in different tibial rotations (neutral tibial rotation, 15° of external tibial rotation, and 15° of internal tibial rotation). The entire examination of each knee was recorded, and AMT including the side-to-side difference (SSD) was assessed using a freely available and validated image analysis software (PIVOT iPad application). Group comparisons were performed using a 1-way analysis of variance with Bonferroni-adjusted post hoc analysis. Intraclass correlation coefficients (ICCs) were calculated to assess inter- and intrarater reliability of AMT measurements. Equivalence of measurements was evaluated using the 2 one-sided t-test procedure. RESULTS Anteromedial rotatory knee laxity was assessed in 30 knees of 15 participants (53% male) with a mean age of 26.2 ± 3.5 years. In all 3 raters, the highest AMT was observed in neutral tibial rotation (range of means, 2.2-3.0 mm), followed by external tibial rotation (range of means, 2.0-2.4 mm) and internal tibial rotation (range of means, 1.8-2.2 mm; P < .05). Intrarater reliability of AMT (ICC, 0.88-0.96) and SSD (ICC, 0.61-0.96) measurements was good to excellent and moderate to excellent, respectively. However, interrater reliability was poor to moderate for AMT (ICC, 0.44-0.73) and SSD (ICC, 0.12-0.69) measurements. Statistically significant equivalence of AMT and SSD measurements was observed between and within raters for almost all testing conditions. CONCLUSION Anteromedial rotatory knee laxity could be quantified using a noninvasive image analysis software, with the highest AMT observed during neutral tibial rotation in uninjured individuals. Reliability and equivalence of measurements were good to excellent within raters and moderate between raters.
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Affiliation(s)
- Lukas Willinger
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Armin Runer
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Romed Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Lukas N. Muench
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Trauma and Reconstructive Surgery, Artemed Klinikum München Süd, Munich, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Philipp W. Winkler
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
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Peez C, Deichsel A, Zderic I, Richards RG, Gueorguiev B, Kittl C, Raschke MJ, Herbst E. Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024; 32:864-871. [PMID: 38454816 DOI: 10.1002/ksa.12110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. METHODS Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5° increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. RESULTS Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 N and 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 N and 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). CONCLUSION Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Borque KA, Han S, Dunbar NJ, Lanfermeijer ND, Sij EW, Gold JE, Ismaily SK, Amis AA, Laughlin MS, Kraeutler MJ, Williams A, Lowe WR, Noble P. Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not. Am J Sports Med 2024; 52:968-976. [PMID: 38343203 DOI: 10.1177/03635465231224477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. PURPOSE To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. STUDY DESIGN Controlled laboratory study. METHODS Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. RESULTS sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. CONCLUSION In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. CLINICAL RELEVANCE In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Shuyang Han
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas J Dunbar
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas D Lanfermeijer
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Ethan W Sij
- UT McGovern Medical School, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Jonathan E Gold
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Sabir K Ismaily
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andrew A Amis
- Imperial College London, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Mitzi S Laughlin
- Houston Methodist Academic Institute, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Matthew J Kraeutler
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andy Williams
- Fortius Clinic, London, UK; FIFA Medical Centre of Excellence, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Walter R Lowe
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Philip Noble
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
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Petersen W, Al Mustafa H, Buitenhuis J, Häner M, Braun K. Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon. Arthrosc Tech 2024; 13:102836. [PMID: 38312881 PMCID: PMC10838056 DOI: 10.1016/j.eats.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/07/2023] [Indexed: 02/06/2024] Open
Abstract
The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.
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Affiliation(s)
- Wolf Petersen
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Hassan Al Mustafa
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Johannes Buitenhuis
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Martin Häner
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Karl Braun
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
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Herbst E, Glasbrenner J, Deichsel A, Briese T, Peez C, Raschke MJ, Kittl C. [Injuries of the medial side of the knee : When and how should they be treated?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:18-26. [PMID: 37848564 PMCID: PMC10787005 DOI: 10.1007/s00113-023-01368-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/19/2023]
Abstract
Different medial structures are responsible for restraining valgus rotation, external rotation, and anteromedial rotation. When injured this can result in various degrees of isolated and combined instabilities. In contrast to earlier speculation, the posterior oblique ligament (POL) is no longer considered to be the main stabilizer of anteromedial rotatory instability (AMRI). Acute proximal medial ruptures are typically managed conservatively with very good clinical results. Conversely, acute distal ruptures usually require a surgical intervention. Chronic instabilities mostly occur in combination with instabilities of the anterior cruciate ligament (ACL). The clinical examination is a particularly important component in these cases to determine the indications for surgery for an additional medial reconstruction. In cases of severe medial and anteromedial instabilities, surgical treatment should be considered. Biomechanically, a combined medial and anteromedial reconstruction appears to be superior to other reconstruction methods; however, there is currently a lack of clinical studies to confirm this biomechanical advantage.
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Affiliation(s)
- Elmar Herbst
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Johannes Glasbrenner
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Adrian Deichsel
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Thorben Briese
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christian Peez
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christoph Kittl
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland.
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Frings J, Behrendt P, Krause M, Frosch KH. [Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:882-888. [PMID: 37773214 DOI: 10.1007/s00132-023-04438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Knee dislocation (KD) is a rare but severe injury of the knee joint, with a high rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. TREATMENT STRATEGY Furthermore, a clear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10 days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require a modified approach, due to a limited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows a high success rate.
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Affiliation(s)
- Jannik Frings
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | | | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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Herbst E, Muhmann RJ, Raschke MJ, Katthagen JC, Oeckenpöhler S, Wermers J, Glasbrenner J, Robinson JR, Kittl C. The Anterior Fibers of the Superficial MCL and the ACL Restrain Anteromedial Rotatory Instability. Am J Sports Med 2023; 51:2928-2935. [PMID: 37503921 DOI: 10.1177/03635465231187043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is limited knowledge about how the anterior cruciate ligament (ACL) and capsuloligamentous structures on the medial side of the knee act to control anteromedial rotatory knee instability. PURPOSE To investigate the contribution of the medial retinaculum, capsular structures (anteromedial capsule, deep medial collateral ligament [MCL], and posterior oblique ligament), and different fiber regions of the superficial MCL to restraining knee laxity, including anteromedial rotatory instability. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic testing system in a position-controlled mode. Loads of 10 N·m valgus rotation, 5 N·m tibial external rotation, 5 N·m tibial internal rotation, and 134 N anterior tibial translation in 5 N·m external rotation were applied at different flexion angles. The motion of the intact knee at 0° to 120° of flexion was replicated after sequential excision of the sartorial fascia; anteromedial retinaculum; anteromedial capsule; anterior, middle, and posterior fibers of the superficial MCL; the deep MCL; the posterior oblique ligament; and the ACL. The reduction in force/torque indicated the contribution of each resected structure to resisting laxity. A repeated-measures analysis of variance with a post hoc Bonferroni test was used to analyze the relative force and torque changes from the intact state. RESULTS The superficial MCL was the most important restraint to valgus rotation from 0° to 120° and provided the largest contribution to resisting external rotation between 30° and 120° of knee flexion, gradually increasing from 25.2% ± 7.4% at 30° to 36.9% ± 15.4% at 90°. The posterior oblique ligament contributed significantly to resisting valgus rotation only in extension (17.2% ± 12.1%) but was the major restraint to internal rotation at 0° (46.7% ± 13.1%) and 30° (30.4% ± 17.7%) of flexion. The sartorial fascia and anteromedial retinaculum resisted ER at all knee flexion angles (P < .05) and was the single most important restraint in the extended knee (19.5% ± 11%). The capsular structures (anteromedial capsule and deep MCL) had a combined contribution of 20% ± 11.5% at 0° and 23.4% ± 10.5% at 120° of knee flexion but were less important from 30° to 90°. The ACL was the primary restraint to anterior tibial translation in external rotation between 0° and 60° of flexion (50.2% ± 16.9% at 30°), but the superficial MCL was more important at 90° to 120° of knee flexion (36.8% ± 16.4% at 90°). The anterior, middle, and posterior regions of the superficial MCL contributed differently to the simulated laxity tests. The anterior fibers were the most important part of the superficial MCL in resisting external rotation and combined anterior tibial translation in external rotation. CONCLUSION The superficial MCL not only was the primary restraint to valgus rotation throughout the range of knee flexion but also importantly contributed to resisting anterior tibial translation in external rotation, particularly in deeper flexion in the cadaveric model. The anterior fibers of the superficial MCL are the most important superficial MCL fibers in resisting anterior tibial translation in external rotation. This study suggests that a medial reconstruction that reproduces the function of the posterior MCL fibers and posterior oblique ligament may not best control anteromedial rotatory instability. CLINICAL RELEVANCE Based on these data, there is a need for an individualized medial reconstruction to address different types of medial injury patterns and instabilities.
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Affiliation(s)
- Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Raphael J Muhmann
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Simon Oeckenpöhler
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Faculty of Engineering Physics, FH Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Kono K, Inui H, Tomita T, Yamazaki T, Konda S, Taketomi S, Tanaka S, D'Lima DD. Bicruciate-retaining total knee arthroplasty procedure reduced tensile force in the middle and posterior components of lateral collateral ligament during deep knee flexion activities with no effect on tensile force of the medial collateral ligament. Knee Surg Sports Traumatol Arthrosc 2023; 31:3889-3897. [PMID: 36928366 DOI: 10.1007/s00167-023-07342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/05/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To analyse the effects of bicruciate-retaining total knee arthroplasty (BCR-TKA) on the tensile force of the collateral ligaments during two deep knee flexion activities, cross-leg sitting and squatting. METHODS Thirteen patients (15 knees) treated using bicruciate-retaining total knee arthroplasty (BCR-TKA) for knee joint osteoarthritis were analysed. Knee joint kinematics during cross-leg sitting (open-chain flexion) and squatting (closed-chain flexion) were evaluated through fluoroscopy. The tensile force was calculated in vivo based on the change in the distance between the femoral and tibial attachment areas for the anterior, middle, and posterior components of the superficial (sMCL) and deep (dMCL) medial collateral ligament and the lateral collateral ligament (LCL). Differences in the calculated tensile forces of the collateral ligaments were evaluated using repeated measures of analysis of variance, with post hoc pairwise comparison (Bonferroni test). Statistical significance was set at P ≤ 0.05. RESULTS The correction of the coronal alignment was related to the surgical technique, not to the implant design. No significant change in the tensile force in all three components of the sMCL from pre- to post-TKA (n.s.) was observed. For dMCL, a pre- to post-TKA change in the tensile force was observed only for the anterior dMCL component (p = 0.03). No change was observed in the tensile force of the anterior LCL with increasing flexion, with no difference in pre- to post-TKA and between activities (n.s.). In contrast, tensile force in the middle LCL slightly decreased with increasing flexion during squatting, pre- and post-TKA. After surgery, lower forces were generated at 40° of flexion (p = 0.04). Tensile force in the posterior LCL was higher in extension than flexion, which remained high in the extension post-TKA. However, after surgery, lower tensile forces were generated at 10° (p = 0.04) and 40° (p = 0.04) of flexion. CONCLUSIONS The in vivo change in tensile forces of the collateral ligaments of the knee before and after BCR-TKA can inform the development of appropriate ligament balancing strategies to facilitate recovery of deep knee flexion activities after TKA, as well as for continued improvement of BCR-TKA designs. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kenichi Kono
- Department of Molecular Medicine Arthritis Research, The Scripps Research Institute, La Jolla, CA, USA
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Master Course of Health Sciences, Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Takaharu Yamazaki
- Department of Information Systems, Faculty of Engineering, Saitama Institute of T1echnology, Fukaya, Saitama, Japan
| | - Shoji Konda
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Darryl D D'Lima
- Department of Molecular Medicine Arthritis Research, The Scripps Research Institute, La Jolla, CA, USA
- Shiley Center for Orthopaedic Research & Education at Scripps Clinic, La Jolla, CA, USA
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Von Rehlingen-Prinz F, Leiderer M, Dehoust J, Dust T, Kowald B, Frosch KH, Izadpanah K, Henes FO, Krause M. Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries. SPORTS MEDICINE - OPEN 2023; 9:70. [PMID: 37553489 PMCID: PMC10409938 DOI: 10.1186/s40798-023-00611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.
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Affiliation(s)
- Fidelius Von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Miriam Leiderer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Tobias Dust
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Birgitt Kowald
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Kaarre J, Runer A, Benvegnu NA, Dadoo S, Persson F, Nammour M, Musahl V, Samuelsson K. Anatomic Flat Double-Bundle Medial Collateral Ligament Reconstruction. Arthrosc Tech 2023; 12:e1265-e1270. [PMID: 37654890 PMCID: PMC10466096 DOI: 10.1016/j.eats.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/18/2023] [Indexed: 09/02/2023] Open
Abstract
Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL.
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Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
- Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Neilen A. Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Fabian Persson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Michael Nammour
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Campos T, Perucci M, Gomes P, Giordano V. Combined reconstruction of medial collateral ligament and posterior cruciate ligament using one femoral tunnel: a technical note and case report applicable to limited-resource settings. BMJ Case Rep 2023; 16:e252877. [PMID: 36882260 PMCID: PMC10008166 DOI: 10.1136/bcr-2022-252877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Knee dislocations are severe injuries difficult to treat. Specially in low-resources scenarios, reconstruction of multiple ligaments can be challenging. We describe a technical note that can be reconstruct multi ligaments using ipsilateral hamstrings autograft. A posteromedial knee incision is made to visualise the medial corner of the knee and to reconstruct medial collateral ligament (MCL) and posterior cruciate ligament (PCL) with semitendinosus and gracilis tendon graft, using one femoral tunnel from the anatomic femoral insertion of the MCL to the anatomic femoral insertion of the PCL. After 1-year follow-up, the patient returned to his previous function with a Lysholm score of 86. This technique can reconstruct more than one ligament anatomically with limited graft resource.
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Affiliation(s)
- Túlio Campos
- Orthopaedic Surgery, Universidade Federal de Minas Gerais Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Marcelo Perucci
- Orthopaedic Surgery, Universidade Federal de Minas Gerais Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Paulo Gomes
- Orthopaedic Surgery, Universidade Federal de Minas Gerais Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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Functional Alignment Philosophy in Total Knee Arthroplasty-Rationale and Technique for the Valgus Morphotype Using an Image Based Robotic Platform and Individualized Planning. J Pers Med 2023; 13:jpm13020212. [PMID: 36836446 PMCID: PMC9961945 DOI: 10.3390/jpm13020212] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023] Open
Abstract
Functional alignment (FA) is a novel philosophy to deliver a total knee arthroplasty (TKA) that respects individual bony and soft tissue phenotypes within defined limitations. The purpose of this paper is to describe the rationale and technique of FA in the valgus morphotype with the use of an image-based robotic-platform. For the valgus phenotype the principles are personalized pre-operative planning, reconstitution of native coronal alignment without residual varus or valgus of more than 3°, restoration of dynamic sagittal alignment within 5° of neutral, implant sizing to match anatomy, and achievement of defined soft tissue laxity in extension and flexion through implant manipulation within the defined boundaries. An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable assessment of soft tissue laxity is performed in extension and flexion. Implant positioning is then manipulated in all three planes if necessary to achieve target gap measurements and a final limb position within a defined coronal and sagittal range. FA is a novel TKA technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that respects variations in individual anatomy and soft tissues within defined limits.
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Anteromediale Rotationsinstabilität des Kniegelenks: Flache sMCL-Bandplastik kombiniert mit einer anteromedialen Rekonstruktion ist der Einzelstrangrekonstruktion des sMCL überlegen. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abermann E, Herbst E, Herbort M, Smigielski R, Fink C. Instabilität des Kniegelenks – medial oder anteromedial? ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zusammenfassung
Hintergrund
Verletzungen des medialen Bandkomplexes gehören zu den häufigsten Knieverletzungen. Sie heilen zwar meist mit konservativer Therapie problemlos aus, persistierende Instabilitäten erhöhen aber die Belastung der Kreuzbänder und benötigen speziell bei deren Beteiligung eine adäquate Therapie.
Anatomie und Biomechanik
Der mediale Seitenbandkomplex besteht im Wesentlichen aus dem oberflächlichen Seitenband (sMCL), welches der primäre Stabilisator gegen Valgus ist, dem tiefen Seitenband (dMCL) mit dessen schräg verlaufendem ventralem Anteil (AML), die nur sekundäre Stabilisatoren gegen Valgus darstellen, aber primär gegen Außenrotation stabilisieren, und dem hinteren Schrägband (POL), das in vollständiger Streckung gegen Valgus sowie gegen Innenrotation stabilisiert.
Therapie
Chronische Instabilitäten bzw. höhergradige Verletzungen mit Dislokation der Bandstümpfe oder multiligamentäre Verletzungen bedürfen einer operativen Versorgung. Im Akutstadium zeigen Avulsionsverletzungen bei anatomischer Refixation gutes Heilungspotenzial, während bei intraligamentären Verletzungen zusätzlich zur Naht der Bandanteile eine Augmentation mit Sehnenmaterial empfohlen wird. Bei chronischen Instabilitäten ist die Differenzierung des Instabilitätsmusters ausschlaggebend für die Wahl der Rekonstruktionstechnik (reine sMCL-Rekonstruktion oder kombinierte Rekonstruktion von sMCL und AML). In beiden Fällen kommt die hier beschriebene Technik mit flachem Transplantat der Anatomie näher als bei konventionellen Verfahren.
Diskussion
Rekonstruktionstechniken unter Verwendung flacher Sehnentransplantate, die alle betroffenen Bandanteile adressieren, haben sich biomechanisch als sehr effektiv erwiesen, komplexe mediale Instabilitäten suffizient zu behandeln. Ob diese auch klinisch überlegen sind, werden zukünftige klinische Studien zeigen müssen.
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Ohliger J, Haus A, Fong R, Lang S, Gilmer BB, Wahl CJ. Modified Bosworth Technique for Medial Collateral Ligament Reconstruction of the Knee Using Semitendinosus Tendon Autograft. Arthrosc Tech 2022; 11:e1903-e1909. [PMID: 36457399 PMCID: PMC9705397 DOI: 10.1016/j.eats.2022.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/08/2022] [Indexed: 02/03/2023] Open
Abstract
The medial collateral ligament (MCL) is a major contributor to knee joint stability and is the most common ligament involved in knee injuries. When conservative management for high-grade MCL injuries fails, operative treatment is indicated. Various reconstruction techniques are described in the literature. The following report describes a reconstruction technique based on the modified Bosworth. We present a step-by-step technique for using autograft semitendinosus tendon as a double limb to reconstruct the MCL and if necessary, the posterior oblique ligament. The technique is versatile with respect to a spectrum of MCL injury patterns, isometric, incorporates techniques that are common to other knee reconstructions, and uses readily available autograft. It has been used extensively by the senior authors as an adjunct/augmentation to the repair of acute MCL injuries as well as in the reconstruction of chronic MCL laxity. The technique restores stability to rotation and valgus stress while maintaining the distal insertion of the semitendinosus intact.
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Affiliation(s)
- James Ohliger
- Barton Center for Orthopedics and Wellness, South Lake Tahoe, California
| | - Andrew Haus
- Barton Center for Orthopedics and Wellness, South Lake Tahoe, California
| | - Rodney Fong
- University of Nevada, Reno School of Medicine, Reno, Nevada
| | - Sarah Lang
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California
| | - Brian B. Gilmer
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California,Address correspondence to Brian Gilmer, M.D., Mammoth Orthopedic Institute, 85 Sierra Park Rd., Mammoth Lakes, CA 93546.
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Wierer G, Kittl C, Fink C, Weiler A. Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability. Arthrosc Tech 2022; 11:e1409-e1418. [PMID: 36061473 PMCID: PMC9437470 DOI: 10.1016/j.eats.2022.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Address correspondence to Guido Wierer, M.D., Department of Orthopedics and Traumatology, Academic Teaching Hospital, Hall in Tirol, Austria.
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Gelenkpunkt Innsbruck, Austria
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Behrendt P, Herbst E, Robinson JR, von Negenborn L, Raschke MJ, Wermers J, Glasbrenner J, Fink C, Herbort M, Kittl C. The Control of Anteromedial Rotatory Instability Is Improved With Combined Flat sMCL and Anteromedial Reconstruction. Am J Sports Med 2022; 50:2093-2101. [PMID: 35604117 PMCID: PMC9227970 DOI: 10.1177/03635465221096464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both the superficial medial collateral ligament (sMCL) and the deep MCL (dMCL) contribute to the restraint of anteromedial (AM) rotatory instability (AMRI). Previous studies have not investigated how MCL reconstructions control AMRI. PURPOSE/HYPOTHESIS The purpose was to establish the optimal medial reconstruction for restoring normal knee kinematics in an sMCL- and dMCL-deficient knee. It was hypothesized that AMRI would be better controlled with the addition of an anatomically shaped (flat) sMCL reconstruction and with the addition of an AM reconstruction replicating the function of the dMCL. STUDY DESIGN Controlled laboratory study. METHODS A 6 degrees of freedom robotic system equipped with a force-torque sensor was used to test 8 unpaired knees in the intact, sMCL/dMCL sectioned, and reconstructed states. Four different reconstructions were assessed. The sMCL was reconstructed with either a single-bundle (SB) or a flattened hamstring graft aimed at better replicating the appearance of the native ligament. These reconstructions were tested with and without an additional AM reconstruction. Simulated laxity tests were performed at 0°, 30°, 60°, and 90° of flexion: 10 N·m valgus rotation, 5 N·m internal and external rotation (ER), and an AM drawer test (combined 134-N anterior tibial drawer in 5 N·m ER). The primary outcome measures of this force-controlled setup were anterior tibial translation (ATT; in mm) and axial tibial rotation (in degrees). RESULTS Sectioning the sMCL/dMCL increased valgus rotation, ER, and ATT with the simulated AM draw test at all flexion angles. SB sMCL reconstruction was unable to restore ATT, valgus rotation, and ER at 30°, 60°, and 90° of flexion to the intact state (P < .05). Flat MCL reconstruction restored valgus rotation at all flexion angles to the intact state (P > .05). ER was restored at all angles except at 90°, but ATT laxity in response to the AM drawer persisted. Addition of an AM reconstruction improved control of ATT relative to the intact state at all flexion angles (P > .05). Combined flat MCL and AM reconstruction restored knee kinematics closest to the intact state. CONCLUSION In a cadaveric model, AMRI resulting from an injured sMCL and dMCL complex could not be restored by an isolated SB sMCL reconstruction. A flat MCL reconstruction or an additional AM procedure, however, better restored medial knee stability. CLINICAL RELEVANCE In patients evaluated with a combined valgus and AM rotatory instability, a flat sMCL and an additional AM reconstruction may be superior to an isolated SB sMCL reconstruction.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany,Department of Anatomy, Christian-Albrechts-University, Kiel, Germany,Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | | | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany,Christoph Kittl, Dr med MD(res), Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany ()
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Hodel S, Hasler J, Fürnstahl P, Fucentese SF, Vlachopoulos L. Elongation Patterns of the Superficial Medial Collateral Ligament and the Posterior Oblique Ligament: A 3-Dimensional, Weightbearing Computed Tomography Simulation. Orthop J Sports Med 2022; 10:23259671221091264. [PMID: 35547613 PMCID: PMC9083062 DOI: 10.1177/23259671221091264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Although length change patterns of the medial knee structures have been reported, either the weightbearing state was not considered or quantitative radiographic landmarks that allow the identification of the insertion sites were not reported. Purpose: To (1) analyze the length changes of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) under weightbearing conditions and (2) to identify the femoral sMCL insertion site that demonstrates the smallest length changes during knee flexion and report quantitative radiographic landmarks. Study Design: Descriptive laboratory study. Methods: The authors performed a 3-dimensional (3D) analysis of 10 healthy knees from 0° to 120° of knee flexion using weightbearing computed tomography (CT) scans. Ligament length changes of the sMCL and POL during knee flexion were analyzed using an automatic string generation algorithm. The most isometric femoral insertion of the sMCL that demonstrated the smallest length changes throughout the full range of motion (ROM) was identified. Radiographic landmarks were reported on an isometric grid defined by a true lateral view of the 3D CT model and transferred to a digitally reconstructed radiograph. Results: The sMCL demonstrated small ligament length changes, and the POL demonstrated substantial shortening during knee flexion ( P = .005). Shortening of the POL started from 30° of flexion. The most isometric femoral sMCL insertion was located 0.6 ± 1.7 mm posterior and 0.8 ± 1.2 mm inferior to the center of the sMCL insertion and prevented ligament length changes >5% during knee flexion in all participants. The insertion was located 47.8% ± 2.7% from the anterior femoral cortex and 46.3% ± 1.9% from the joint line on a true lateral 3D CT view. Conclusion: The POL demonstrated substantial shortening starting from 30° of knee flexion and requires tightening near full extension to avoid overconstraint. Femoral sMCL graft placement directly posteroinferior to the center of the anatomical insertion of the sMCL demonstrated the most isometric behavior during knee flexion. Clinical Relevance: The described elongation patterns of the sMCL and POL aid in guiding surgical medial knee reconstruction and preventing graft lengthening and overconstraint of the medial compartment. Repetitive graft lengthening is associated with graft failure, and overconstraint leads to increased compartment pressure, cartilage degeneration, and restricted ROM.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Julian Hasler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 2022; 30:167-175. [PMID: 33661325 PMCID: PMC8800884 DOI: 10.1007/s00167-021-06514-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures. METHODS Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. RESULTS Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. CONCLUSION The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lukas Willinger
- Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Foundation Trust, London, UK ,Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | | | - Vishal Pai
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Justin Lee
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Adam Mitchell
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
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Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:280-287. [PMID: 33616694 DOI: 10.1007/s00167-021-06502-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/10/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. METHODS This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. RESULTS Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18-52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24-72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). CONCLUSION Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. LEVEL OF EVIDENCE IV.
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Requicha F, Comley A. Medial soft-tissue complex of the knee: Current concepts, controversies, and future directions of the forgotten unit. Orthop Rev (Pavia) 2021; 13:24463. [PMID: 34745468 DOI: 10.52965/001c.24463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022] Open
Abstract
The medial side of the knee is comprised of ligaments, myotendinous and meniscal structures that work as a unit to stabilize the joint. The superficial medial collateral ligament is its core structure. Still, all elements of the medial side have load-sharing relationships, leading to a cascade of events in the scenario of insufficiency of any of them. Understanding the medial soft tissue structures as part of a unit is of utmost importance because the most common ligaments damaged in knee injuries belong to it. Surprisingly, there is a lack of high-level evidence published around the issue, and most studies focus on the superficial medial collateral ligament, overlooking the complexity of these injuries. Acknowledging the consequences for joint biomechanics and treatment outcomes, interest in this area is growing between researchers. Emerging evidence may become a game-changer in the future management of these injuries. Based on a thorough research of published literature, this review provides a current biomechanical concepts and clinical guidance to treat these injuries.
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Glasbrenner J, Herbst E, Raschke MJ, Peez C, Briese T, Kittl C. Anteromedial Rotatory Laxity: What is it, When to Address, and How? OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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