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Holuba K, Vermeijden HD, Yang XA, O'Brien R, van der List JP, DiFelice GS. Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous. Arthroscopy 2023; 39:1099-1107. [PMID: 35817377 DOI: 10.1016/j.arthro.2022.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.
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Affiliation(s)
- Kurt Holuba
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Harmen D Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.; Department of Orthopaedic Surgery, Amsterdam UMC Location, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences-Sports, Amsterdam, the Netherlands
| | - Xiuyi A Yang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Robert O'Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.; Department of Orthopaedic Surgery, Amsterdam UMC Location, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences-Sports, Amsterdam, the Netherlands
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A..
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Chapman G, Vij N, LaPrade R, Amin N. Medial-Sided Ligamentous Injuries of the Athlete's Knee: Evaluation and Management. Cureus 2023; 15:e36360. [PMID: 37082476 PMCID: PMC10112817 DOI: 10.7759/cureus.36360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/22/2023] Open
Abstract
The superficial medial collateral ligament (sMCL) is the most commonly injured ligamentous structure in the knee. The other medial knee stabilizers include the deep medial collateral ligament, the posterior oblique ligament, and the medial meniscus. Medial collateral ligament injuries frequently occur in young athletes. As a result of the good healing capacity of the sMCL, the majority of acute medial-sided knee injuries can be treated nonoperatively with good outcomes. However, missed concomitant injuries can lead to residual laxity and instability of the knee when treated conservatively. When surgical management is warranted, numerous techniques exist, including repair, augmentation, and reconstruction. Recent anatomic and biomechanical studies defining the attachment sites and functional roles of the individual medial knee structures have led to advancements in diagnosis, treatment, and rehabilitation. These studies have allowed for the development of an anatomic reconstruction technique that restores the native stability and load-sharing relationships among the medial knee structures. The purpose of this narrative review is to summarize the recent updates in the anatomy, biomechanics, evaluation, and treatment of ligamentous injuries on the medial side of the athlete's knee.
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Affiliation(s)
| | - Neeraj Vij
- Orthopedic Surgery, University of Arizona College of Medicine, Phoenix, USA
| | | | - Nirav Amin
- Orthopedic Surgery, Restore Orthopedics and Spine Center, Orange, USA
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Makaram NS, Murray IR, Geeslin AG, Chahla J, Moatshe G, LaPrade RF. Diagnosis and treatment strategies of the multiligament injured knee: a scoping review. Br J Sports Med 2023; 57:543-550. [PMID: 36822842 DOI: 10.1136/bjsports-2022-106425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs). DESIGN Scoping review. DATA SOURCES Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary. RESULTS Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups. CONCLUSIONS There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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Thompson JW, Rajput V, Kayani B, Plastow R, Magan A, Haddad FS. Surgical Repair of Stener-like Injuries of the Medial Collateral Ligament of the Knee in Professional Athletes. Am J Sports Med 2022; 50:1815-1822. [PMID: 35593741 DOI: 10.1177/03635465221093807] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A "Stener-like" lesion of the knee is defined as a distal avulsion of the superficial medial collateral ligament (sMCL) with interposition of the pes anserinus between the ligament and its tibial insertion-a displacement impeding anatomic healing. Because of the scarcity of these injuries, the literature is limited to case reports and small case series. PURPOSE To assess the effect of surgical repair of acute Stener-like lesions of the sMCL on the following outcomes: return to preinjury level of sporting function; time to return to preinjury level of sporting function; functional performance; injury recurrence; and any other complications. STUDY DESIGN Case series: Level of evidence, 4. METHODS This prospective single-surgeon study included 23 elite athletes with a mean age of 27.2 years (range, 19-37 years). Of the participants, 20 were men (87%) and 3 were women (13%). The mean body mass index was 23.1 ± 2.3. A total of 16 athletes were soccer players (70%) and 7 were rugby players (30%), with isolated acute, traumatic Stener-like lesions of the sMCL of the knee confirmed on preoperative magnetic resonance imaging. Surgical repair was undertaken with primary suture anchor repair with ligament repair or reconstruction system (LARS) augmentation. Predefined outcomes were recorded at regular intervals after surgery. The minimum follow-up time was 24 months (range, 24-108 months) from the date of surgery. RESULTS The mean time from injury to surgical intervention was 9 days (range, 3-28 days). Overall, 15 (65%) athletes had isolated distal sMCL injuries requiring anatomic suture anchor repair at the distal tibial insertion site only, and 8 (35%) athletes had concomitant injuries of the proximal and distal sMCL and required anatomic suture anchor repair at the proximal and distal attachment sites. Ten athletes required LARS augmentation at the time of the index operation. All study patients returned to their preinjury level of sporting activity in professional soccer or rugby. The mean time from surgical intervention to return to full sporting activity was 16.8 ± 2.7 weeks. At 6 and 24 months' follow-up, all patients had Tegner scores of 10. At a 2-year follow-up, all study patients were still participating at their preinjury level of sporting activity. Three patients developed complications around the LARS that required further surgery to remove synthetic material; however, this did not affect function. CONCLUSION Surgical repair of acute Stener-like lesions of the sMCL is associated with a high return to preinjury level of sporting function, excellent functional performance, and a low risk of recurrence at short-term follow-up in elite athletes.
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Affiliation(s)
- Joshua W Thompson
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Vishal Rajput
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Babar Kayani
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Ricci Plastow
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Ahmed Magan
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Fares S Haddad
- Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Department of Trauma & Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
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The association of bone bruising and grade of MCL injury in patients sustaining isolated MCL injuries. Skeletal Radiol 2022; 51:1073-1080. [PMID: 34628510 DOI: 10.1007/s00256-021-03932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the incidence of bone bruising with isolated medial collateral ligament injury and to assess whether the presence of bone bruising is related to the injury grade. MATERIALS AND METHODS Patients who sustained an acute isolated medial collateral ligament injury demonstrated on knee MRI between 2016 and 2020 were included in this study. Patient's characteristics and injury classification (clinical and radiological) were reviewed from clinical notes and imaging. The patients were divided into two groups, based on the presence of bone bruising. Fisher's exact test was used for dichotomous variables and odds ratios were computed in areas of clinical significance. RESULTS Sixty patients with a median age of 37.6 ± 13.8 were included. Twenty-eight (46.7%) had bone bruising demonstrated on MRI scan. The bone bruising group were 7 times (95% CI [1.4;36.5]) more likely to have a complete disruption of the superficial medial collateral ligament and MRI grade III injury. Injury to the deep medial collateral ligament was more often observed in this group (p < 0.05). The most common location of bone bruising was the lateral femoral condyle (57.1%, 16/28) and/or the medial femoral condyle (57.1%, 16/28). CONCLUSIONS The incidence of bone bruising with isolated medial collateral ligament injury is significant and is more common with radiologically higher grade injuries. There was no statistically significant difference between the anatomical location of bone bruise and the grade of MCL injury. Bone bruising patterns can help determine the mechanism of injury, with a valgus impact or avulsion type injury most commonly seen.
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Iyengar K, Jain V, Gupta H, Azzopardi C, Botchu R. Iyengar-Botchu (IB) confluence of the medial knee- anatomy and clinico-radiological review. J Clin Orthop Trauma 2021; 22:101591. [PMID: 34567973 PMCID: PMC8447233 DOI: 10.1016/j.jcot.2021.101591] [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] [Received: 06/25/2021] [Revised: 09/02/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022] Open
Abstract
The Iyengar-Botchu confluence is a quadrilateral space on the medial side of the knee. Due to the presence of unique anatomical structures, this region is prone to injuries. The aim of this pictorial review is to illustrate an anatomical description of the structures, which form the IB complex confluence. Clinico-pathological correlation of common conditions associated with these structures will increase awareness of injuries in this area. A complementary imaging guidance will support clinical diagnosis and appropriate patient management.
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Affiliation(s)
- K.P. Iyengar
- Department of Orthopedics, Southport &Ormskirk NHS Trust, Southport, UK
| | - V.K. Jain
- Department of Orthopedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - H. Gupta
- Department of Musculoskeletal Radiology, Leeds Teaching Hospitals, Leeds, UK
| | - C. Azzopardi
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - R. Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK,Corresponding author. Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham, UK.
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Ciba M, Winkelmeyer EM, Schock J, Schad P, Kotowski N, Nolte T, Wollschläger LM, Knobe M, Prescher A, Kuhl C, Truhn D, Nebelung S. Comprehensive Assessment of Medial Knee Joint Instability by Valgus Stress MRI. Diagnostics (Basel) 2021; 11:diagnostics11081433. [PMID: 34441368 PMCID: PMC8392372 DOI: 10.3390/diagnostics11081433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 01/19/2023] Open
Abstract
Standard clinical MRI techniques provide morphologic insights into knee joint pathologies, yet do not allow evaluation of ligament functionality or joint instability. We aimed to study valgus stress MRI, combined with sophisticated image post-processing, in a graded model of medial knee joint injury. To this end, eleven human cadaveric knee joint specimens were subjected to sequential injuries to the superficial medial collateral ligament (sMCL) and the anterior cruciate ligament (ACL). Specimens were imaged in 30° of flexion in the unloaded and loaded configurations (15 kp) and in the intact, partially sMCL-deficient, completely sMCL-deficient, and sMCL- and ACL-deficient conditions using morphologic sequences and a dedicated pressure-controlled loading device. Based on manual segmentations, sophisticated 3D joint models were generated to compute subchondral cortical distances for each condition and configuration. Statistical analysis included appropriate parametric tests. The medial compartment opened gradually as a function of loading and injury, especially anteriorly. Corresponding manual reference measurements by two readers confirmed these findings. Once validated in clinical trials, valgus stress MRI may comprehensively quantify medial compartment opening as a functional imaging surrogate of medial knee joint instability and qualify as an adjunct diagnostic tool in the differential diagnosis, therapeutic decision-making, and monitoring of treatment outcomes.
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Affiliation(s)
- Malin Ciba
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Eva-Maria Winkelmeyer
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Justus Schock
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany; (J.S.); (L.M.W.)
| | - Philipp Schad
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Niklas Kotowski
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Teresa Nolte
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Lena Marie Wollschläger
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany; (J.S.); (L.M.W.)
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Andreas Prescher
- Institute of Anatomy, RWTH Aachen University, 52074 Aachen, Germany;
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Daniel Truhn
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, Aachen University Hospital, 52074 Aachen, Germany; (M.C.); (E.-M.W.); (P.S.); (N.K.); (T.N.); (C.K.); (D.T.)
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany; (J.S.); (L.M.W.)
- Correspondence:
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Carneiro BC, Araújo FF, Guimarães JB, Chemin RN, Jorge RB, Filho AGO, Nico MAC. Stener-like lesions in the hand, knee and foot: a review of anatomy, mechanism of injury and imaging evaluation. Clin Imaging 2021; 76:235-246. [PMID: 33975225 DOI: 10.1016/j.clinimag.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
A Stener lesion is a displaced tear of the ulnar collateral ligament in the metacarpophalangeal joint of the thumb in which the adductor pollicis aponeurosis is positioned between the retracted ligament and the injury site, preventing natural healing. This lesion was first described in 1962, and since then, both radiologists and orthopedists have considered it important to treat surgically. Although this lesion was originally described in the thumb, this injury mechanism can occur in other joints of the hand, knee, and foot. The purpose of this study was to review the relevant aspects of classic Stener lesions of the thumb, as well as other Stener-like lesions, including their anatomy, mechanisms of lesion formation and imaging features. The Stener-like injury pattern often necessitates surgical repair or reconstruction; thus, it is essential that radiologists recognize and report the different patterns of injury.
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Affiliation(s)
- Bruno Cerretti Carneiro
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Flávia Ferreira Araújo
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Júlio Brandão Guimarães
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Renan Nogueira Chemin
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Rafael Baches Jorge
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Alípio Gomes Ormond Filho
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
| | - Marcelo Astolfi Caetano Nico
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde Higienópolis, Rua Mato Grosso 306, 1° Andar, Higienópolis, São Paulo, SP 01239-040, Brazil.
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D’Ambrosi R, Corona K, Guerra G, Cerciello S, Ursino C, Ursino N, Hantes M. Posterior oblique ligament of the knee: state of the art. EFORT Open Rev 2021; 6:364-371. [PMID: 34150330 PMCID: PMC8183151 DOI: 10.1302/2058-5241.6.200127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The posterior oblique ligament (POL) is the predominant ligamentous structure on the posterior medial corner of the knee joint. A thorough understanding of the anatomy, biomechanics, diagnosis, treatment and rehabilitation of POL injuries will aid orthopaedic surgeons in the management of these injuries.The resulting rotational instability, in addition to valgus laxity, may not be tolerated by athletes participating in pivoting sports. The most common mechanism of injury - accounting for 72% of cases - is related to sports activity, particularly football, basketball and skiing. Moreover, three different injury patterns have been reported: those associated with injury to the capsular arm of the semimembranosus (SM), those involving a complete peripheral meniscal detachment and those involving disruption of the SM and peripheral meniscal detachment.The hallmark of an injury related to POL lesions is the presence of anteromedial rotatory instability (AMRI), which is defined as 'external rotation with anterior subluxation of the medial tibial plateau relative to the distal femur'.In acute settings, POL lesions can be easily identified using coronal and axial magnetic resonance imaging (MRI) where the medial collateral ligament (MCL) and POL appear as separate structures. However, MRI is not sensitive in chronic cases.Surgical treatment of the medial side leads to satisfactory clinical results in a multi-ligamentous reconstruction scenario, but it is known to be associated with secondary stiffness.In young patients with high functional demands, return to sports is allowed no earlier than 9-12 months after they have undergone a thorough rehabilitation programme. Cite this article: EFORT Open Rev 2021;6:364-371. DOI: 10.1302/2058-5241.6.200127.
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Affiliation(s)
| | - Katia Corona
- Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
| | - Simone Cerciello
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
- Casa di Cura Villa Betania, Rome, Italy
- Marrelli Hospital, Crotone, Italy
| | | | | | - Michael Hantes
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessalia, University Hospital of Larissa, Larissa, Greece
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10
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Stevens KJ, Albtoush OM, Lutz AM. The Stieda fracture revisited. Skeletal Radiol 2021; 50:945-953. [PMID: 33034705 DOI: 10.1007/s00256-020-03645-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to evaluate injury patterns associated with Stieda avulsion fractures of the medial femoral condyle at the attachment of the proximal MCL. MATERIALS AND METHODS Knee radiographs and MRI scans of 11 patients with Stieda fractures were evaluated by two fellowship-trained MSK radiologists for fracture origin, integrity of the deep and superficial components of the MCL, medial retinacular structures, posterior oblique ligament, other ligamentous injuries, meniscal tears, and osteochondral injuries. The mechanism of injury and subsequent clinical management were recorded. RESULTS Eight Stieda fractures only involved the meniscofemoral fibers of the deep MCL, two larger Stieda fractures related to both superficial and deep layers, and one fracture only involved the superficial layer. Posteromedial retinacular structures and posterior oblique ligament were injured in all cases. Eight had high-grade ACL injuries, but none had high-grade PCL nor FCL injuries. The proximal anterolateral ligament was injured in seven, including two with associated Segond fractures. Other injuries included posterolateral corner injuries in six, meniscal injuries in seven, and additional fractures in nine, most commonly ACL-associated impaction fractures in the lateral tibiofemoral compartment. None had high-grade chondral injury. None of the Stieda fractures were treated surgically, but four underwent subsequent ACL reconstruction. CONCLUSION Stieda fractures most commonly involved the deep fibers of the MCL and were accompanied by moderate-to-high-grade injury of other MCL components. There was a high association with other ligamentous injuries, particularly the posterior medial retinacular structures, posterior oblique ligament, and ACL, and many were associated with additional fractures.
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Affiliation(s)
- Kathryn J Stevens
- Department of Radiology, Stanford University Medical Center, Grant Building S062A, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Omar M Albtoush
- Department of Diagnostic and Interventional Radiology, University of Jordan, Queen Rania Street, Amman, 11942, Jordan
| | - Amelie M Lutz
- Department of Radiology, Stanford University Medical Center, Grant Building S062A, 300 Pasteur Drive, Stanford, CA, 94305, USA
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Rocha de Faria JL, Pedrinha ISM, Pavão DM, Albuquerque RPE, Sousa EBD, Mandarino M, Mozella ADP. Stress Radiography for Multiligament Knee Injuries: A Standardized, Step-by-Step Technique. Arthrosc Tech 2020; 9:e1885-e1892. [PMID: 33381396 PMCID: PMC7768114 DOI: 10.1016/j.eats.2020.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023] Open
Abstract
Physical examination in the presence of a multiligament knee injury can be complex and challenging. Hence, stress radiography is a useful and inexpensive tool that is widely used in the assessment of this type of injury. It guarantees an objective analysis of the magnitude of knee instability, which may reduce the observer's interpretation bias in relation to the physical examination. However, for the radiographic analysis to be reproducible, it is necessary to standardize the technique to evaluate each of the main knee ligaments. This article aims to describe in detail how to perform stress radiography to assess the sufficiency of the posterior cruciate ligament and collateral ligaments in the context of a multiligament injury.
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Affiliation(s)
- José Leonardo Rocha de Faria
- Address correspondence to José Leonardo Rocha de Faria, M.D., Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Av Brasil, 500, São Cristovão, Rio de Janeiro, Brazil, CEP 20940-070.
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Yoo JY, Park HG, Kwon SM. Influence of posteromedial corner injuries on clinical outcome and second-look arthroscopic findings after allograft transtibial anterior cruciate ligament reconstruction. Knee Surg Relat Res 2020; 32:41. [PMID: 32778169 PMCID: PMC7418298 DOI: 10.1186/s43019-020-00061-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 07/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the influence of posterior medial corner (PMC) injuries on clinical outcome and second-look arthroscopic findings after anterior cruciate ligament (ACL) reconstruction. METHODS Seventy-eight consecutive patients underwent a second-look arthroscopic surgery after ACL reconstruction and magnetic resonance imaging (MRI) examination of the PMC. The patients were divided into a PMC intact group (n = 42) and a PMC injured group (n = 36). The stability and clinical outcomes were evaluated using the Lachman test, pivot-shift test, a KT-2000 arthrometer, and the Lysholm knee scoring scale. Graft tension and synovial coverage were evaluated in second-look arthroscopy. RESULTS The clinical function showed no significant differences regarding PMC injury. Although the graft tendon tension revealed no significant differences (p = 0.141), the second-look arthroscopic findings indicated that the PMC intact group showed better synovial coverage compared to the PMC injured group (p = 0.012). CONCLUSION Patients who injured the PMC had poor synovial coverage as assessed by second-look arthroscopic findings after transtibial ACL reconstruction, even though clinical outcomes and stability showed no significant differences.
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Affiliation(s)
- Jun-Young Yoo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro, Dongnam-gu, Cheonan-si, Chungnam, 330-715, Republic of Korea
| | - Hee-Gon Park
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro, Dongnam-gu, Cheonan-si, Chungnam, 330-715, Republic of Korea.
| | - Soon-Min Kwon
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro, Dongnam-gu, Cheonan-si, Chungnam, 330-715, Republic of Korea
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MRI findings of Stener-like lesion of the knee: A case series with surgical correlation. Eur J Radiol 2019; 121:108709. [PMID: 31669799 DOI: 10.1016/j.ejrad.2019.108709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/21/2019] [Accepted: 10/09/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe the MRI findings of the "Stener-like" lesion of the knee and its distinction from simple medial collateral ligament (MCL) tear. A "Stener-like" lesion of the superficial medial collateral ligament is a tear involving the distal fibers, where the torn fibers become displaced superficial to the pes anserinus fibers, a displacement which can prevent healing. METHODS Nine cases of Stener-like lesion were prospectively diagnosed on MRI. Retrospective, IRB-approved, HIPAA-compliant chart review was performed to determine correlation of surgical and MRI findings. Seven cases were surgically confirmed and are included in the series. RESULTS MRI is useful in making the diagnosis of Stener-like lesions and prompting the surgeon to explore the distal MCL. Coronal MRI shows variable proximal retraction of the torn ligament. It has a lax contour and abuts the pes anserinus. The proximity of the torn ligament end to the pes can result in misdiagnosis of a partial tear. Axial images are useful to confirm position of the ligament superficial to the pes. All cases had associated tear of the deep MCL fibers, as well as sprains of the proximal superficial MCL. CONCLUSIONS It is important to recognize the Stener-like lesion because this lesion is usually managed surgically, while most MCL tears are managed conservatively. The presence of injury to the proximal MCL is usually present, and may be a distractor from the distal injury. Care must be taken to include the distal attachment of the sMCL on coronal MRI images.
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Lundblad M, Hägglund M, Thomeé C, Hamrin Senorski E, Ekstrand J, Karlsson J, Waldén M. Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study. Knee Surg Sports Traumatol Arthrosc 2019; 27:3692-3698. [PMID: 30949749 PMCID: PMC6800843 DOI: 10.1007/s00167-019-05491-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Medial collateral ligament (MCL) injury is the single most common traumatic knee injury in football. The purpose of this study was to study the epidemiology and mechanisms of MCL injury in men's professional football and to evaluate the diagnostic and treatment methods used. METHODS Fifty-one teams were followed prospectively between one and three full seasons (2013/2014-2015/2016). Individual player exposure and time-loss injuries were recorded by the teams' medical staffs. Moreover, details on clinical grading, imaging findings and specific treatments were recorded for all injuries with MCL injury of the knee as the main diagnosis. Agreement between magnetic resonance imaging (MRI) and clinical grading (grades I-III) was described by weighted kappa. RESULTS One hundred and thirty of 4364 registered injuries (3%) were MCL injuries. Most MCL injuries (98 injuries, 75%) occurred with a contact mechanism, where the two most common playing situations were being tackled (38 injuries, 29%) and tackling (15 injuries, 12%). MRI was used in 88 (68%) of the injuries, while 33 (25%) were diagnosed by clinical examination alone. In the 88 cases in which both MRI and clinical examination were used to evaluate the grading of MCL injury, 80 (92% agreement) were equally evaluated with a weighted kappa of 0.87 (95% CI 0.77-0.96). Using a stabilising knee brace in players who sustained a grade II MCL injury was associated with a longer lay-off period compared with players who did not use a brace (41.5 (SD 13.2) vs. 31.5 (SD 20.3) days, p = 0.010). CONCLUSION Three-quarter of the MCL injuries occurred with a contact mechanism. The clinical grading of MCL injuries showed almost perfect agreement with MRI grading, in cases where the MCL injury is the primary diagnosis. Not all grade II MCL injuries were treated with a brace and may thus indicate that routine bracing should not be necessary in milder cases. LEVEL OF EVIDENCE Prospective cohort study, II.
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Affiliation(s)
- Matilda Lundblad
- Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
- Football Research Group, Linköping University, Linköping, Sweden.
| | - Martin Hägglund
- Football Research Group, Linköping University, Linköping, Sweden
- Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Ekstrand
- Football Research Group, Linköping University, Linköping, Sweden
- Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jón Karlsson
- Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Football Research Group, Linköping University, Linköping, Sweden
| | - Markus Waldén
- Football Research Group, Linköping University, Linköping, Sweden
- Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Abstract
The posteromedial corner of the knee encompasses five medial structures posterior to the medial collateral ligament. With modern MRI systems, these structures are readily identified and can be appreciated in the context of multiligamentous knee injuries. It is recognized that anteromedial rotatory instability results from an injury that involves both the medial collateral ligament and the posterior oblique ligament. Like posterolateral corner injuries, untreated or concurrent posteromedial corner injuries resulting in rotatory instability place additional strain on anterior and posterior cruciate ligament reconstructions, which can ultimately contribute to graft failure and poor clinical outcomes. Various options exist for posteromedial corner reconstruction, with early results indicating that anatomic reconstruction can restore valgus stability and improve patient function. A thorough understanding of the anatomy, physical examination findings, and imaging characteristics will aid the physician in the management of these injuries.
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Naraghi AM, White LM. Imaging of Athletic Injuries of Knee Ligaments and Menisci: Sports Imaging Series. Radiology 2017; 281:23-40. [PMID: 27643766 DOI: 10.1148/radiol.2016152320] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute knee injuries are a common source of morbidity in athletes and if overlooked may result in chronic functional impairment. Magnetic resonance (MR) imaging of the knee has become the most commonly performed musculoskeletal MR examination and is an indispensable tool in the appropriate management of the injured athlete. Meniscal and ligamentous tearing are the most frequent indications for surgical intervention in sports injuries and an understanding of the anatomy, biomechanics, mechanisms of injury, and patterns of injury are all critical to accurate diagnosis and appropriate management. These will be discussed in reference to meniscal tears and injuries of the cruciate ligaments as well as injuries of the posterolateral and posteromedial corners of the knee. (©) RSNA, 2016.
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Affiliation(s)
- Ali M Naraghi
- From the Department of Medical Imaging, University of Toronto, Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4
| | - Lawrence M White
- From the Department of Medical Imaging, University of Toronto, Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4
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Möller I, Szkudlarek M. Imaging of regional pain syndromes; from syndromes to conditions using imaging? Best Pract Res Clin Rheumatol 2016; 30:707-719. [PMID: 27931963 DOI: 10.1016/j.berh.2016.06.001] [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] [Received: 05/24/2016] [Revised: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 11/17/2022]
Abstract
Musculoskeletal regional pain syndromes often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can in most cases reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods have to support the clinical assessment. This paper presents the underlying pathologies of the most frequently encountered regional pain syndromes and the role of musculoskeletal ultrasonography and magnetic resonance imaging in their visualization. It presents data, where available, on diagnostic accuracy and comparisons with gold standards. The article stresses the advantages and disadvantages of the analyzed imaging modalities and suggests the future research agenda.
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Affiliation(s)
- Ingrid Möller
- Instituto Poal de Reumatologia, University of Barcelona, Barcelona, Spain; Department of Rheumatology, Zealand's University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Marcin Szkudlarek
- Department of Rheumatology, Zealand's University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
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Guler O, Isyar M, Karataş D, Ormeci T, Cerci H, Mahirogulları M. Investigating the relationship between internal tibial torsion and medial collateral ligament injury in patients undergoing knee arthroscopy due to tears in the posterior one third of the medial meniscus. Knee 2016; 23:655-8. [PMID: 26751979 DOI: 10.1016/j.knee.2015.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/07/2015] [Accepted: 09/30/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the relationship between medial collateral ligament (MCL) injury and degree of internal tibial torsion in patients who had undergone arthroscopic resection due to tears in the posterior one third of the medial meniscus. METHODS Seventy-one patients were allocated into two groups with respect to foot femur angle (FFA) and transmalleolar angle (TMA) (Group 1 31 patients with FFA<8° and Group 2 40 patients with FFA≥8°). The groups were compared in terms of valgus instability, Lysholm score, magnetic resonance view, FFA, and TMA, both before and after the operation. RESULTS Lysholm scores were higher in Group 2 at both postoperative week 1 (p<0.001) and month 1 (p=0.045) relative to Group 1. Preoperative cartilage injury was encountered more frequently in Group 1 (p=0.037) than in Group 2. MCL injury was detected more frequently in Group 1 compared to Group 2 postoperatively at week 1 (p=0.001). CONCLUSION We conclude that FFA and TFA, indicators of internal tibial torsion, may serve as markers for foreseeing clinical improvement and complications following arthroscopic surgery. LEVEL OF EVIDENCE level III retrospective comparative study.
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Affiliation(s)
- Olcay Guler
- Department of Orthopedics and Traumatology, Medipol University, Medical Faculty, Istanbul, Turkey.
| | - Mehmet Isyar
- Department of Orthopedics and Traumatology, Medipol University, Medical Faculty, Istanbul, Turkey
| | - Dilek Karataş
- Department of Radiology, Nisa Hospital, Istanbul, Turkey
| | - Tugrul Ormeci
- Department of Radiology, Medipol University, Medical Faculty, Istanbul, Turkey
| | - Halis Cerci
- Department of Orthopedics and Traumatology, Nisa Hospital, Istanbul, Turkey
| | - Mahir Mahirogulları
- Department of Orthopedics and Traumatology, Medipol University, Medical Faculty, Istanbul, Turkey
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