Semitendinosus tenodesis for medial instability of the knee

Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG)

Background:

Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined.

Purpose:

To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL.

Study Design:

Consensus statement.

Methods:

Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests.

Results:

The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements.

Conclusion:

The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.

Management of medial-sided knee injuries

Medial collateral ligament injuries are common and are often associated with concomitant ligamentous, meniscus, and cartilage injuries. Orthopedic surgeons should be familiar with the outcomes of nonoperative and operative treatment of isolated and combined grade I, II, and III injuries. Special attention should be paid to identifying involvement of the posterior oblique ligament and capsule; lack of such attention may lead to failed nonoperative management. The authors present an overview of the treatment of medial-sided knee injuries, as well as 2 cases demonstrating their preferred method of treating chronic medial-sided laxity and instability.

Does sequence of graft tensioning affect outcomes in combined anterior and posterior cruciate ligament reconstructions?

BACKGROUND

Controversy persists regarding the protocol for tensioning and securing the grafts in one-stage reconstruction of combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. Many authors have reported stability examinations and functional results after reconstruction for this relatively rare injury, and the best sequence for tensioning the grafts is not known.

QUESTIONS/PURPOSES

We sought to determine (1) if there are differences in postoperative anteroposterior stability in a protocol of simultaneous tensioning of both grafts and ACL-first fixation compared with a protocol of tensioning and fixation of the PCL first in one-stage reconstruction of combined ACL/PCL injuries; and (2) if there is a difference in postoperative functional outcome scores between the two protocols.

METHODS

Between 2001 and 2011, 29 patients underwent one-stage reconstruction of combined ACL and PCL injuries (the majority with medial collateral ligament [MCL] injuries, posterolateral corner [PLC] injuries, or both, in addition), of whom three patients (10%) were lost to followup before 2 years, and one patient was excluded based on predefined criteria, leaving a total of 25 patients (86%) for retrospective analysis in this report. Fourteen patients underwent one-stage reconstruction of these injuries with tensioning and fixation of the PCL graft first (PCL-first group), and 11 later patients underwent one-stage reconstruction of combined ACL/PCL injuries with simultaneous tensioning of both grafts and fixation of the ACL graft first (simultaneous-tensioning group). During the period in question, the technique used in the PCL-first group was used exclusively for these injuries between August 2001 and August 2008 and that used in the simultaneous-tensioning group was used between September 2008 and August 2011; there was no overlap between groups. The groups were similar in terms of demographics and length of followup. Each patient was assessed for associated injuries, preoperative and postoperative knee stability with anteroposterior stress radiographs, and was evaluated with the Lysholm knee score and International Knee Documentation Committee (IKDC) subjective and objective grading at the last followup after surgery.

RESULTS

At the last followup evaluation, patients treated with simultaneous tensioning and ACL-first fixation showed less instability on side-to-side difference of posterior stress radiography (5±1 mm in the simultaneous-tensioning group versus 6±1 mm in the PCL-first group; effect size, 1.2; 95% confidence interval [CI], 0.5-2.3; p=0.011), but with the numbers available, no difference on anterior stress radiography (3±0.4 mm in the simultaneous-tensioning group versus 3±0.5 mm in PCL-first group; effect size, 0.4; 95% CI, -0.2 to 0.5; p=443). The simultaneous-tensioning group also had higher Lysholm knee scores (87±5 in the simultaneous-tensioning group versus 80±4 in the PCL-first group; effect size, 1.8; 95% CI, -10.9 to -2.7; p=0.001), IKDC subjective scores (68±3 in the simultaneous-tensioning group versus 58±3 in the PCL-first group; effect size, 3.4; 95% CI, -14.2 to -8.6; p<0.001), and IKDC objective grades (p=0.037).

CONCLUSIONS

In one-stage reconstruction of combined ACL and PCL injuries, a protocol of simultaneous tensioning both grafts and fixing the ACL graft first may be worth consideration. Arthroscopic reduction landmarks may prove helpful in this technique but require further validation.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Acute medial collateral ligament injuries of the knee: diagnostics and therapy]

The medial collateral ligament complex (MCL) is the most commonly damaged ligamentous stabilizer of the human knee. The diagnostic algorithm comprises patient history, clinical examination and magnetic resonance imaging (MRI). It is important to distinguish between incomplete and complete ruptures of the MCL. For adequate treatment the classification and exact knowledge about concomitant injuries are important. A nonoperative treatment of incomplete ruptures (grades I and II) is widely accepted and usually results in a good clinical outcome but the treatment of complete ruptures (grade III) is a subject of controversy. Complete intraligamentous ruptures with a correct approximation of the stumps and intact dorsomedial joint capsule can also be treated nonoperatively with good and excellent results. In contrast, ruptures close to the abutment and bony avulsions tend to heal better through operative treatment. Dehiscence or dislocation of the ligament stumps in MRI is an indication for operative treatment. In the context of a multiligamentous injury or complex instability, the majority of authors suggest an operative stabilization. As the treatment of chronic instability can be challenging, the initial and adequate treatment of acute ruptures is of great importance.

[Minimally invasive augmentation of the medial collateral ligament with autologous hamstring tendons in chronic knee instability]

OBJECTIVE

Medial collateral ligament reconstruction in chronic unstable knees.

INDICATIONS

Chronic instability of the medial collateral ligament (MCL) isolated or in combination with multiligament injuries.

CONTRAINDICATIONS

Refixable bony avulsions, limited range of motion, arthrofibrosis, severe valgus deformity, infections, critical soft tissue, lack of patient compliance and open growth plates.

SURGICAL TECHNIQUE

Harvesting of the contralateral semitendinosus tendon and preparation. Supine position with leg in electric leg holder. Oblique skin incision above the pes anserinus parallel to the tendons. Placement of drill hole distal to the tibial insertion of the hamstrings in the footprint of the MCL. Tapering and fixation of the transplant. Subfascial tunneling and femoral fixation of the transplant distally to the medial patellofemoral ligament (MPFL) origin in 30° flexion under fluoroscopic control. Tibial fixation of the dorsal portion of the transplant (POL) ventral to the semimembranosus tendon footprint in full extension.

POSTOPERATIVE MANAGEMENT

Limited weight bearing with 20 kg for 4-6 weeks, stabilizing brace with limited range of motion 0/0/90°.

RESULTS

A total of 9 patients with a median age of 39 (18-70) years received an augmentation of the MCL complex due to a chronic instability using the described technique. Follow-up examination was performed after 16 (11-56) months. All patients reported a stable knee. The median value of the Lysholm score at follow-up was 90 (72-96) points and the Tegner score prior to trauma was 4 (2-6) points and 3 (2-6) points during follow-up. No grade 2 or 3 instability could be observed during follow-up. There were no complications using the above mentioned technique.

The superficial medial collateral ligament reconstruction of the knee: effect of altering graft length on knee kinematics and stability

PURPOSE

The purpose of this study was to evaluate and compare the resulting knee kinematics and stability of an anatomic superficial MCL (sMCL) reconstruction and a non-anatomic sMCL reconstruction.

METHODS

In a cadaveric model, normal knee stability and kinematics were compared with sMCL deficient knees and with two experimental sMCL reconstructions. The first reconstruction (AnatRecon) attempted to anatomically reconstruct the sMCL. The second reconstruction (ShortRecon) used a shorter graft to mimic the effect of failing to reproduce the anatomic length of the sMCL. Changes in position of the femur with respect to the tibia were measured with an electromagnetic tracking system during simulated active knee extension and during passive knee stability testing in the sMCL intact knee, the sMCL deficient knee, and the two experimental reconstructions.

RESULTS

Simulated active knee extension demonstrated a significant increase in external tibial rotation of ShortRecon compared to AnatRecon between 30° and 80° of knee flexion (mean difference <3.0° over the range of knee flexion angles; P < 0.008), and a significant increase in external tibial rotation of ShortRecon compared to the intact sMCL was found at 60° and 70° of knee flexion (mean difference <2.0°over the range of knee flexion angles; P < 0.008). Passive joint stability testing demonstrated that division of the sMCL produced approximately 6° of valgus laxity at 30° of knee flexion and increased external tibial rotation of approximately 5° at 30°, 9° at 60°, and 10° at 90° of knee flexion, respectively. AnatRecon restored normal knee kinematics and stability. Additionally, passive stability testing demonstrated a significant increase in external tibial rotation of ShortRecon compared to AnatRecon at 60° (mean difference = 3.7°; P < 0.05) and 90° of knee flexion (mean difference = 4.9°; P < 0.05).

CONCLUSION

Anatomic reconstruction of the sMCL effectively restored knee kinematics and stability in the sMCL deficient knee. Altering the normal ligament length resulted in measurable changes in knee kinematics and stability. This study suggests that in cases of chronic valgus knee instability, anatomic sMCL reconstruction would provide better results than non-anatomic sMCL reconstruction.

Structural properties of the primary medial knee ligaments

BACKGROUND

The structural properties of the individual components of the superficial medial collateral ligament (MCL), deep MCL, and posterior oblique ligament (POL) have not been studied in isolation. To define the necessary strength requirements for an anatomical medial knee reconstruction, knowledge of these structural properties is necessary.

HYPOTHESIS

The components of the superficial MCL, POL, and deep MCL have significantly different structural properties.

STUDY DESIGN

Controlled laboratory study.

METHODS

This study used 20 fresh-frozen nonpaired cadaveric knee specimens with a mean age of 54 years (range, 27 to 68 years). These knees provided 8 samples for each tested medial knee structure, which was individually isolated and loaded to failure at 20 mm per minute. Specifically tested were the superficial MCL with intact femoral and detached proximal tibial attachments, the superficial MCL with intact femoral and detached distal tibial attachments, the central arm of the POL, and the isolated deep MCL. Load was recorded as a function of displacement. Stiffness of the ligament at failure was calculated from these measurements.

RESULTS

The mean load at failure for the superficial MCL with the intact femoral and distal tibial attachments was 557 N. Mean load at failure was 88 N for the intact femoral and proximal tibial divisions of the superficial MCL, 256 N for the POL, and 101 N for the deep MCL. Stiffness of the ligaments just before failure was 63, 17, 38, and 27 N/mm, in the same order as above.

CONCLUSION

The proximal and distal tibial divisions of the superficial MCL, POL, and deep MCL produced loads of clinical importance.

CLINICAL RELEVANCE

Knowledge of the structural properties of these attachment sites will assist in reconstruction graft choices, fixation method choices, and overall operative treatment of medial knee injury.

Medial collateral ligament injuries of the knee: current treatment concepts

The medial collateral ligament is one of the most commonly injured ligaments of the knee. Most injuries result from a valgus force on the knee. The increased participation in football, ice hockey, and skiing has all contributed to the increased frequency of MCL injuries. Prophylactic knee bracing in contact sports may prevent injury; however, performance may suffer. The majority of patients who sustain an MCL injury will achieve their pre-injury activity level with non-operative treatment alone; however, those with combined ligamentous injuries may require acute operative care. Accurate characterization of each aspect of the injury will help to determine the optimum treatment plan.

Injuries to the medial collateral ligament and associated medial structures of the knee

*The superficial medial collateral ligament and other medial knee stabilizers-i.e., the deep medial collateral ligament and the posterior oblique ligament-are the most commonly injured ligamentous structures of the knee. *The main structures of the medial aspect of the knee are the proximal and distal divisions of the superficial medial collateral ligament, the meniscofemoral and meniscotibial divisions of the deep medial collateral ligament, and the posterior oblique ligament. *Physical examination is the initial method of choice for the diagnosis of medial knee injuries through the application of a valgus load both at full knee extension and between 20 degrees and 30 degrees of knee flexion. *Because nonoperative treatment has a favorable outcome, there is a consensus that it should be the first step in the management of acute isolated grade-III injuries of the medial collateral ligament or such injuries combined with an anterior cruciate ligament tear. *If operative treatment is required, an anatomic repair or reconstruction is recommended.

Clinical comparison of anteromedial versus anterolateral tibial tunnel direction for transtibial posterior cruciate ligament reconstruction: 2 to 8 years' follow-up

BACKGROUND

It has been suggested that transtibial posterior cruciate ligament reconstruction may be compromised by graft abrasion at the "killer turn," where the graft emerges from the tibia. In 1998, one of the authors suggested that beginning the tibial tunnel anterolaterally rather than anteromedially would reduce the killer turn and possibly improve the results of posterior cruciate ligament reconstruction.

PURPOSE

This article is intended to present the clinical results of single-bundle transtibial posterior cruciate ligament reconstruction, comparing cases in which the tibial tunnel was begun anteromedially with cases in which the tunnel was begun anterolaterally.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors retrospectively studied 23 patients (group I) using the anteromedial tibial tunnel technique from April 1998 to August 2003 and 37 patients (group II) using the anterolateral tibial tunnel technique from February 1998 to August 2003. The average follow-up period was 58.6 months in group I and 56.9 months in group II. The minimum follow-up period was 24 months in each group. All revision cases and patients with general laxity were excluded.

RESULTS

The mean side-to-side difference of posterior tibial translation by Telos stress radiography was 3.98 +/- 1.27 mm (range, 1.80-7.80 mm) in group I and 2.87 +/- 1.25 mm (range, 1.43-6.82 mm) in group II, which was a statistically significant difference (P < .01). The final mean Lysholm knee score was 88.6 +/- 7.10 points (range, 77-98 points) in group I and 88.4 +/- 6.44 points (range, 78-98 points) in group II, which was not a statistically significant difference (P = .4358). According to the final International Knee Documentation Committee (IKDC) evaluation in group I, 30.4% (7 of 23) were normal (A), 60.9% (14 of 23) were nearly normal (B), and 8.7% (2 of 23) were abnormal (C). In group II, 24.3% (9 of 37) were normal (A), 73.0% (27 of 37) were nearly normal (B), and 2.7% (1 of 37) were abnormal (C) (P = .467). With respect to the mean side-to-side difference of range of motion, there was no statistically significant difference (P = .1697). The mean was 4.7 degrees +/- 2.38 degrees (range, 2 degrees -10 degrees ) in group I and 4.0 degrees +/- 1.73 degrees (range, 0 degrees -8 degrees ) in group II.

CONCLUSION

The anterolateral tibial tunnel technique is preferred to the anteromedial technique in terms of the objective results; however, clinical results as judged by Lysholm and IKDC scores are not significantly correlated to these results.

Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads

BACKGROUND

There is limited information regarding load responses of the posterior oblique and superficial medial collateral ligaments to applied loads.

HYPOTHESES

The degree of knee flexion affects loads experienced by the posterior oblique ligament and both divisions of the superficial medial collateral ligament. The posterior oblique ligament provides significant resistance to valgus and internal rotation forces near knee extension. Different load responses are experienced by proximal and distal divisions of the superficial medial collateral ligament.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twenty-four nonpaired, fresh-frozen cadaveric knees were tested. Buckle transducers were applied to the proximal and distal divisions of the superficial medial collateral and posterior oblique ligaments. Applied loads at 0 degrees, 20 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion consisted of 10 N m valgus loads, 5 N.m internal and external rotation torques, and 88 N anterior and posterior drawer loads.

RESULTS

External rotation torques produced a significantly higher load response on the distal superficial medial collateral ligament than did internal rotation torques at all flexion angles with the largest difference at 90 degrees (96.6 vs 22.5 N). For an applied valgus load at 60 degrees of knee flexion, loads on the superficial medial collateral ligament were significantly higher in the distal division (103.5 N) than the proximal division (71.9 N). The valgus load response of the posterior oblique ligament at 0 degrees of flexion (19.1 N) was significantly higher than at 30 degrees (10.6 N), 60 degrees (7.8 N), and 90 degrees (6.8 N) of flexion. At 0 degrees of knee flexion, the load response to internal rotation on the posterior oblique ligament (45.8 N) was significantly larger than was the response on both divisions of the superficial medial collateral ligament (20 N for both divisions). At 90 degrees of flexion, the load response to internal rotation torques reciprocated between these structures with a significantly higher response in the distal superficial medial collateral ligament division (22.5 N) than the posterior oblique ligament (9.1 N).

CONCLUSION

The superficial medial collateral ligament experienced the largest load response to applied valgus and external rotation torques; the posterior oblique ligament observed the highest load response to internal rotation near extension.

CLINICAL RELEVANCE

This study provides new knowledge of the individual biomechanical function of the main medial knee structures in an intact knee and will assist in the interpretation of clinical knee motion testing and provide evidence for techniques involving repair or reconstruction of the posterior oblique ligament and both divisions of the superficial medial collateral ligament.

Chronic multiple knee ligament injuries: epidemiological analysis of more than one hundred cases

INTRODUCTION

Diagnosis and treatment of multiple ligament injuries of the knee remain a real challenge for most surgeons.

OBJECTIVE

To find out the epidemiological profile of patients surgically treated at a Reference Service with more than one chronic ligament injury in the knee joint.

MATERIALS AND METHODS

Of a total of 978 operated patients, 109 presented at least two associated ligament injuries in the same knee. Demographic and clinical variables were evaluated.

RESULTS

The anterior cruciate ligament group presented a larger number of cases of ligament injuries related with sports practice and falls, while the posterior cruciate ligament and anterior cruciate ligament + posterior cruciate ligament groups presented more cases related to traffic accidents and trauma with object (weight on the knee) (p<0.001). The varus group presented significantly higher values of time since injury (p<0.01). In the group with new anterior cruciate ligament injury (neoligament) associated with other ligament injuries the disruption times were higher, showing statistical significance (p<0.001).

CONCLUSIONS

Anterior cruciate ligament injury associated with other ligament injuries other than posterior cruciate ligament injury are related to sports practice and falls. Posterior cruciate ligament injury associated to other ligament injuries, including or not anterior cruciate ligament injury, are related to traffic accidents and direct trauma caused by an object on the knee. Significant delay between primary ligament injuries and their reconstructions generates varus deformity of the affected knee. In spite of the large delay in seeking medical treatment, few patients with neoligament anterior cruciate ligament injury and other combined disruptions will develop varus deformity.

A New Methodology to Determine the Anatomical Center and Radius of Curved Joint Surfaces

This study describes a mechanical tool which allows us to determine the radius and center of curved joint surfaces both intraoperatively and in vitro. The tool is composed of longitudinal parallel hinges, connected with cross bars on one end. In the middle of each cross bar, one needle is attached at an angle of 90deg to both the hinges and the cross bars. When the parallel hinges are held against a curved surface, they will adapt to the curvature and the needles on the cross bars will cross each other. The crossing point of two needles represents the mean center of the curvature within the plane spanned by the needles. The radius is the distance between the center of curvature and the joint surface. The proposed tool and method allow us to determine the mean center of convex or concave curvatures, which often represent the isometric point of a corresponding curved joint surface. Knowing the radius and center of curvature may facilitate various surgical procedures such as collateral or cruciate ligament reconstruction. Appropriate adaptations of the tool appear to be a useful basis for biomechanical and anatomical joint analyses in the laboratory.

Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results

The purpose of the study was to evaluate the mid-term results of surgical treatment in different groups of patients with multiple knee ligament injuries. Review of our patients' records revealed that 48 acute and chronic patients were surgically treated for combined knee injury. Due to severe capsular damage in these injuries, open techniques were used. In our treatment protocol, avulsed ligaments and tears of the posterolateral and posteromedial corner were repaired if possible, whereas midsubstance tears of cruciate ligaments and chronic cases were reconstructed with autografts. Postoperatively, an accelerated program of rehabilitation was introduced, aiming to progressively mobilize the joint and improve muscle endurance. For the follow-up evaluation we designed a protocol composed of two parts. In the first part, anatomical lesions were recorded and in the second part, clinical evaluation was performed using the Lysholm score, the Tegner rating system, the IKDC evaluation form, and the KT1000. Student's t tests and chi-square tests were used for data analysis. Forty-eight patients (mean age 28.6+/-11.9 years; 41 males) were classified according to the specific anatomical structures involved. Group A included 12 anterior cruciate ligament (ACL) and medial structure injuries, group B included 11 ACL or posterior cruciate ligament (PCL) ruptures combined with posterolateral injuries, and group C consisted of 25 knee dislocations (ACL and PCL ruptures which might be combined with damage of the collateral ligaments). Thirty-eight patients were surgically treated during the acute phase and ten patients were treated chronically. Forty-four patients (91.6%) were followed up at a mean of 51.3+/-29.9 months. Average Lysholm score was 87+/-12.3; average Tegner score was 5.09+/-2.19 before accident and 4.34+/-2.12 in re-examination; IKDC score was A in 10 cases, B in 22, C in 6, and D in 6. The mean range of motion was 129.9 degrees +/-12.5 degrees . The average loss of extension and flexion were 1.6 degrees +/-2.5 degrees and 7.6 degrees +/-7.9 degrees , respectively. The side-to-side difference in corrected anterior and posterior translation in quadriceps neutral angle and in anterior translation in 30 degrees angle was <3 mm for about 65% of our patients. Surgical treatment of multiple knee ligament injuries, using autografts, provided satisfactory stability, range of motion, and subjective functional results. However, despite the improvement of the quality of life, the preinjury patients' activity level was not fully obtained in re-examination. Patients underwent surgical treatment during the acute phase had better scores in several points, but finally there was no statistical significance between acute and chronic patients. Moreover, no statistically significant differences were observed among the groups with specific damaged anatomical structures.