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Petersen W, Mustafa HA, Buitenhuis J, Braun K, Häner M. [Reconstruction of the medial collateral ligament complex with a flat semitendinosus auto- or allograft]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024:10.1007/s00064-024-00856-8. [PMID: 39172277 DOI: 10.1007/s00064-024-00856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 08/23/2024]
Abstract
OBJECTIVE Replacement of superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with an allograft. INDICATIONS Chronic 3° isolated medial instability and combined anteromedial or posteromedial instability. CONTRAINDICATIONS Infection, open growth plates, restricted range of motion (less than E/F 0-0-90°). SURGICAL TECHNIQUE Longitudinal incision from medial epicondyle to superficial pes anserinus and exposure of the medial collateral ligament complex. Thawing of the allogeneic semitendinosus tendon graft at room temperature, reinforcement of the tendon ends with sutures and preparation of a two-stranded graft. Placement of guidewires in the sMCL and POL insertions and control with image intensifier. Tunnel drilling. Pulling the graft loop into the femoral bone tunnel and fixation with a flip button. Pulling the two graft ends into the tibial tunnels. Tibial fixation by knotting the suture ends in a 20° flexion on the lateral cortex. Suture the tendon bundles to the remaining remnants of the medial collateral ligament complex to adopt the flat structure of the natural medial collateral ligament complex. POSTOPERATIVE MANAGEMENT Six weeks partial weight-bearing, immediately postoperatively splint in the extended position, after 2 weeks movable knee brace for another 4-6 weeks. Mobility: 4 weeks 0-0-60, 5th and 6th weeks 0-0-90. RESULTS From 2015-2021, this surgical procedure was performed in 19 patients (5 women, 14 men, age 34 years). Mean Lysholm score at follow-up after at least 2 years was 89 (76-99) points. In 6 patients, there was restricted range of motion 3 months postoperatively, which resulted in further therapy (3 × systemic cortisone therapy, 3 × arthroscopically supported manipulations under anesthesia).
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Affiliation(s)
- Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland.
| | - Hassan Al Mustafa
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Johannes Buitenhuis
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Karl Braun
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Martin Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
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Jones M, Pinheiro VH, Church JS, Ball SV, Williams A. Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39010719 DOI: 10.1002/ksa.12363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 07/17/2024]
Abstract
PURPOSE This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play (RTP) rates and levels, career longevity and complications. METHODS A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTP was defined as competing at professional level or national/international level in amateur sport. RESULTS There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP. CONCLUSION Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mary Jones
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Vitor H Pinheiro
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - J Samuel Church
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Simon V Ball
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Andy Williams
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
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Blaber OK, DeFoor MT, Aman ZA, McDermott ER, DePhillipo NN, Dickens JF, Dekker TJ. Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis. JBJS Rev 2024; 12:01874474-202406000-00007. [PMID: 38913807 DOI: 10.2106/jbjs.rvw.24.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.
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Affiliation(s)
- Olivia K Blaber
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Zachary A Aman
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Emily R McDermott
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | | | | | - Travis J Dekker
- Department of Orthopaedics Surgery, 10th Medical Group, US Air Force Academy, Colorado Springs, Colorado
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Olivos-Meza A, Hernández-Espinoza EM, Domínguez-Hernández VM, Araujo-Monsalvo VM, Estrada-Villaseñor EG, Pichardo-Bahena R, Murguía-González LÁ, Rodríguez-Reinoso JD, de Jesus Hernández-León J, Landa-Solis C. Biomechanical and histological comparison of two suture configurations for soft tissue grafts: speedtrap™ versus krackow stitch. Cell Tissue Bank 2024; 25:705-712. [PMID: 38724712 DOI: 10.1007/s10561-024-10133-4] [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: 02/21/2023] [Accepted: 01/30/2024] [Indexed: 06/01/2024]
Abstract
To compare 2 different graft preparation techniques to determine biomechanical strength and resultant tissue trauma evaluated by histology. Twelve common flexors of the finger's tendons were prepared with either tubulization (SpeedTrap™) or transtendon stiches (Orthocord™). The stiffness, resistance and energy at maximum load were tested for biomechanical assessment in both groups. After load testing, Samples were stained with hematoxylin and eosin (HE) to evaluate histological damage. We observe that the time to prepare tendons with SpeedTrap™ was 8.3 times faster (1:25 min) than traditional ones (15:02 min). In all cases, the mean values for SpeedTrap™ were higher in terms of strength, stiffness and energy at maximum load than for traditional suture but without significant difference (p > 0.05). The Krackow stitch produces greater structural damage to the collagen fibers while SpeedTrap™ maintains better organized arrangement of the fibers after tubulization preparation. With the results obtained, we can conclude that the tubulization technique allows faster graft preparation with less structural damage to the manipulated tissue without altering the biomechanical resistance provided by the transtendon suture technique.
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Affiliation(s)
- Anell Olivos-Meza
- Orthopedics and Traumatology, Hospital Medica Sur, Mexico City, Mexico
| | - Edgar Manuel Hernández-Espinoza
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Víctor Manuel Araujo-Monsalvo
- Head of the Biomechanics Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Raúl Pichardo-Bahena
- Head of Pathological Anatomy Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Luis Ángel Murguía-González
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Juan Diego Rodríguez-Reinoso
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Jonatan de Jesus Hernández-León
- Orthopedic Sports Medicine and Arthroscopy Department, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Carlos Landa-Solis
- Investigator, Tissue Engineering, Cell Therapy and Regenerative Medicine Unit, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Calzada México Xochimilco 289, 14389, Mexico City, Mexico.
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Julian KR, Mulakaluri A, Truong NM, Fernandez A, Kamal RN, Shapiro LM. Are Orthopaedic Clinical Trials Linguistically and Culturally Diverse? A Systematic Review. JBJS Rev 2024; 12:e24.00012. [PMID: 39021638 PMCID: PMC11250675 DOI: 10.2106/jbjs.rvw.24.00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Purpose Underrepresentation and misrepresentation of historically underrepresented populations in randomized controlled trials (RCTs) may have implications for the validity of research results and their application for diverse populations. To evaluate the representation of historically linguistically, racially, and ethnically underrepresented participants in orthopaedic randomized controlled trials (RCTs) and to assess the use of translated and culturally adapted patient reported outcome measures (PROMs). Methods Separate and comprehensive literature searches of PubMed, Web of Science, and Embase databases were performed to identify RCTs utilizing PROMs between the years 2012 - 2022 among the top five highest 5-year impact factor orthopaedic journals according to the 2021 Journal Citation Reports database. The primary outcomes of interest included reporting of linguistic, racial and ethnic demographic characteristics of trial participants and the utilization of translated PROMs. The methodological quality of each clinical trial was assessed using the Jadad Criteria. Results 230 RCTs met inclusion criteria. The language of participants was reported in 14% of trials and in 17% of trials when searching both the published text and clinical trial registration information. In addition, race and/or ethnicity was reported in 11% of trials, and the use of translated PROMs was reported in 7% of trials. Among the six multinational studies, none reported the language of the study population nor the use of translated PROMs. Notably, four studies (2%) reported utilizing culturally adapted PROMs. The average Jadad score was 3.07. Conclusion Participant language, race, and ethnicity are infrequently reported in orthopaedic clinical trials, potentially limiting the application and interpretation of study results. Similarly, the linguistic and cultural adaptation of PROMs utilized are often not reported, which also limits interpretations of the validity and generalizability of orthopedic study results. Researchers and journals should promote standard reporting of demographic data and methods of PROM adaptation to ensure results are generalizable to diverse patient populations. Level of Evidence III.
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Affiliation(s)
- Kaitlyn R. Julian
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Ashley Mulakaluri
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Nicole M. Truong
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Alicia Fernandez
- Department of Medicine, University of California – San Francisco, 1001 Potrero Ave #107, San Francisco, CA 94110
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Redwood City, CA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
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Blackwood NO, Blitz JA, Vopat B, Ierulli VK, Mulcahey MK. Medial Collateral Ligament Reconstruction With Autograft Versus Allograft: A Systematic Review. Am J Sports Med 2024:3635465231225982. [PMID: 38476106 DOI: 10.1177/03635465231225982] [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: 03/14/2024]
Abstract
BACKGROUND Medial collateral ligament (MCL) reconstruction (MCLR) is performed after failed nonoperative treatment or high-grade MCL injury with associated valgus instability. PURPOSE To evaluate clinical outcomes after MCLR with autograft versus allograft. STUDY DESIGN Systematic review, Level of evidence, 4. METHODS A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors conducted a search of the PubMed, CINAHL, EMBASE, and Cochrane databases to identify studies comparing outcomes of MCLR with autograft versus allograft. Studies were included if they evaluated clinical outcomes after MCLR using autograft and/or allograft. Any study that included concomitant knee ligament injury other than the anterior cruciate ligament injury was excluded. A quality assessment was performed using the modified Coleman Methodology Score. RESULTS The initial search identified 746 studies, 17 of which met the inclusion criteria and were included in this review. The studies included 307 patients: 151 (49.2%) patients received autografts, and 156 (50.8%) received allografts. The most used autograft was the semitendinosus tendon (136 grafts; 90.1% of specified allografts), and the only allograft used was the Achilles tendon (110 grafts; 100% of specified autografts). The mean follow-up of the studies was 25.6 months. Postoperative pain (Lysholm scores) ranged from 82.9 to 94.8 in patients receiving autografts and 87.5 to 93 in patients receiving allografts. Postoperative range of motion was full in 8 of 15 (53.3%) patients receiving autografts compared with 82 of 93 (88.2%) patients receiving allografts. Five of the 151 (3.3%) patients who had MCLR with autografts had complications such as infection, instability, and prominent screws. Two of the 156 (1.3%) MCLRs with allografts developed complications of prominent screws and nonhealing incisions. CONCLUSION MCLR with either autografts or allografts leads to improved patient-reported, radiographic, and clinical outcomes. Patient-reported postoperative pain was similar in patients receiving either graft type. Other outcomes were difficult to compare between graft types because of nonstandardized reporting and a lack of pre- and postoperative measurements. Therefore, there is no evidence of significantly improved outcomes in the use of either autograft or allograft with MCLR.
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Affiliation(s)
| | - Jack A Blitz
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Bryan Vopat
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Victoria K Ierulli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
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Jang YH, Kim DS. Atelocollagen Injections Improve Outcomes in the Nonsurgical Treatment of Grade III Medial Collateral Ligament Injuries. Clin Orthop Surg 2023; 15:953-959. [PMID: 38045580 PMCID: PMC10689225 DOI: 10.4055/cios23022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 12/05/2023] Open
Abstract
Background The purpose of this study was to evaluate the clinical outcomes of atelocollagen injections in isolated grade III medial collateral ligament (MCL) injuries of the knee joint. Methods A total of 50 participants were included in this retrospective study. Twenty-six patients underwent conservative treatment with a single atelocollagen injection, while the remaining patients underwent only typical conservative treatment. All participants underwent magnetic resonance imaging to identify and grade MCL injury. Valgus stress radiography was performed on both knees at 6 and 12 months after the injury. The visual analog scale (VAS) score was collected at the first visit and at 2 weeks, 6 weeks, 6 months, and 12 months after injury. The International Knee Documentation Committee (IKDC) formula activity level and Lysholm score were evaluated for patient-reported outcomes at the first visit and at 6 and 12 months after injury. The participant's return to the pre-injury activity level ratio was measured by comparing the IKDC formula activity level at 12 months after the injury with that before the injury. Results The VAS and Lysholm scores improved over time in both groups. The VAS and Lysholm scores were significantly better in the collagen injection group than in the control group. Regarding the activity level, the collagen injection group showed significantly better results at the 6-month follow-up, but there was no significant difference at the 12-month follow-up. The medial gap in the injured knee and the side-to-side difference (SSD) in both groups gradually decreased over time. The SSD in the collagen injection group was significantly smaller than that in the control group. Conclusions Atelocollagen injections resulted in better clinical and radiologic outcomes along with a higher rate of return to the pre-injury activity level, thereby exhibiting a positive effect in the nonsurgical treatment of grade III MCL injuries.
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Affiliation(s)
- Young Hwan Jang
- Department of and Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
- Yonsei Institute of Sports Science and Exercise Medicine, Wonju, Korea
| | - Doo Sup Kim
- Department of and Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
- Yonsei Institute of Sports Science and Exercise Medicine, Wonju, Korea
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Thompson AA, Bolia IK, Fathi A, Dobitsch A, Cruz CA, Grewal R, Weber AE, Petrigliano FA, Hatch III GF. Tissue Augmentation Techniques in the Management of Ligamentous Knee Injuries. Orthop Res Rev 2023; 15:215-223. [PMID: 38028655 PMCID: PMC10657762 DOI: 10.2147/orr.s385817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
Despite early reports of high failure rates in knee ligament repair techniques resulting in favor of reconstruction, newer advances in surgical technology have shifted the attention back to repair with the addition of various tissue augmentation techniques. Ligament repair preserves proprioceptors in the native ligament and avoids autograft tendon harvest, minimizing the complications associated with donor site ruptures in reconstruction techniques. Tissue augmentation has been successfully used in knee ligamentous and tendon repair procedures, as well as in some upper extremity procedures. This study provides a clinical update on the surgical techniques, biomechanics, and outcomes with the application of various tissue augmentation techniques in the ligaments surrounding the knee joint.
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Affiliation(s)
- Ashley A Thompson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Andrew Dobitsch
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Christian A Cruz
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Rajvarun Grewal
- California Health Sciences University, Clovis, CA, 93612, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
| | - George F Hatch III
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA
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Mowers C, Jackson GR, Condon JJ, Dhillon N, Brusalis CM, Khan ZA, Batra A, Jawanda H, Mameri ES, Kaplan DJ, Knapik DM, Verma NN, Chahla J. Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review. Arthroscopy 2023; 39:2231-2240. [PMID: 36898592 DOI: 10.1016/j.arthro.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Affiliation(s)
- Colton Mowers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joshua J Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nireet Dhillon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Christopher M Brusalis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anjay Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Enzo S Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Instituto Brasil de Tecnologia da Saúde, Rio de Janeiro, Brazil; Department of Orthopedics and Traumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Daniel J Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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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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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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Casp AJ, Bryniarski A, Brady AW, Fossum BW, Godin JA. Reanalysis of the Posterior Oblique Ligament: Quantitative Anatomy, Radiographic Markers, and Biomechanical Properties. Orthop J Sports Med 2023; 11:23259671231174857. [PMID: 37378276 PMCID: PMC10291147 DOI: 10.1177/23259671231174857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/22/2023] [Indexed: 06/29/2023] Open
Abstract
Background The posterior oblique ligament (POL) is the largest structure of the posteromedial knee that is at risk of injury in conjunction with the medial collateral ligament (MCL). Its quantitative anatomy, biomechanical strength, and radiographic location have not been assessed in a single investigation. Purpose To evaluate the 3-dimensional and radiographic anatomy of the posteromedial knee and the biomechanical strength of the POL. Study Design Descriptive laboratory study. Methods Ten nonpaired fresh-frozen cadaveric knees were dissected and medial structures were elevated off bone, leaving the POL. The anatomic locations of the related structures were recorded with a 3-dimensional coordinate measuring machine. Anteroposterior and lateral radiographs were taken with radiopaque pins inserted into the pertinent landmarks, and the distances between the collected structures were calculated. Each knee was then mounted to a dynamic tensile testing machine, and pull-to-failure testing was performed to record the ultimate tensile strength, stiffness, and failure mechanism. Results The POL femoral attachment was a mean of 15.4 mm (95% CI, 13.9-16.8 mm) posterior and 6.6 mm (95% CI, 4.4-8.8 mm) proximal to the medial epicondyle. The tibial POL attachment center was a mean of 21.4 mm (95% CI, 18.1-24.6 mm) posterior and 2.2 mm (95% CI, 0.8-3.6 mm) distal to the center of the deep MCL tibial attachment and a mean of 28.6 mm (95% CI, 24.4-32.8 mm) posterior and 41.9 mm (95% CI, 36.8-47.0 mm) proximal to the center of the superficial MCL tibial attachment. On lateral radiographs, the femoral POL was a mean of 17.56 mm (95% CI, 14.83-21.95 mm) distal to the adductor tubercle and 17.32 mm (95% CI, 14.6-21.7 mm) posterosuperior to the medial epicondyle. On the tibial side, the center of the POL attachment was a mean of 4.97 mm (95% CI, 3.85-6.79 mm) distal to the joint line on anteroposterior radiographs and 6.34 mm (95% CI, 5.01-8.48 mm) distal to the tibial joint line on lateral radiographs, at the far posterior tibial aspect. The biomechanical pull-to-failure demonstrated a mean ultimate tensile strength of 225.2 ± 71.0 N and a mean stiffness of 32.2 ± 13.1 N. Conclusion The anatomic and radiographic locations of the POL and its biomechanical properties were successfully recorded. Clinical Relevance This information is useful to better understand POL anatomy and biomechanical properties as well as to clinically address an injury with repair or reconstruction.
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Affiliation(s)
- Aaron J. Casp
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Alex W. Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Jonathan A. Godin
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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13
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Lee CS, Jeon OH, Han SB, Jang KM. Mesenchymal Stem Cells for Enhanced Healing of the Medial Collateral Ligament of the Knee Joint. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040725. [PMID: 37109683 PMCID: PMC10146272 DOI: 10.3390/medicina59040725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/21/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: The medial collateral ligament (MCL) is one of the major supporting ligaments of the knee joint, and MCL injuries are common where excessive valgus loading is applied to the knee joint. Although most MCL injuries can be treated conservatively, healing of the MCL can take several weeks to months. Furthermore, once injured, the biomechanical properties of the healed MCL differ from those of the native MCL, resulting in an increased risk of re-injury and chronic remnant symptoms. Mesenchymal stem cells (MSCs), owing to their therapeutic potential, have been investigated in various musculoskeletal injuries, and some preclinical studies regarding MSC-based approaches in MCL injuries have shown promising results. Despite satisfactory results in preclinical studies, there is still a lack of clinical studies in the orthopedic literature. This article describes the basic knowledge of the MCL, standard treatments for MCL injuries, and recent studies regarding the application of MSCs for enhanced healing of the MCL. MSC-based approaches are expected to be a potential therapeutic option for enhanced healing of the MCL in the future.
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Affiliation(s)
- Chul-Soo Lee
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ok-Hee Jeon
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Clinical Research Progress of Internal Brace Ligament Augmentation Technique in Knee Ligament Injury Repair and Reconstruction: A Narrative Review. J Clin Med 2023; 12:jcm12051999. [PMID: 36902785 PMCID: PMC10004357 DOI: 10.3390/jcm12051999] [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: 01/24/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Knee ligament injuries are most common in sports injuries. In general, ligament repair or reconstruction is necessary to restore the stability of the knee joint and prevent secondary injuries. Despite advances in ligament repair and reconstruction techniques, a number of patients still experience re-rupture of the graft and suboptimal recovery of motor function. Since Dr. Mackay's introduction of the internal brace technique, there has been continuous research in recent years using the internal brace ligament augmentation technique for knee ligament repair or reconstruction, particularly in the repair or reconstruction of the anterior cruciate ligament. This technique focuses on increasing the strength of autologous or allograft tendon grafts through the use of braided ultra-high-molecular-weight polyethylene suture tapes to facilitate postoperative rehabilitation and avoid re-rupture or failure. The purpose of this review is to present detailed research progress in the internal brace ligament enhancement technique of knee ligament injury repair as well as the reconstruction from biomechanical and histological research and clinical studies and to comprehensively assess the value of the application of this technique.
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15
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Zhang H. Comparative Outcomes After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: Letter to the Editor. Am J Sports Med 2022; 50:NP51-NP52. [PMID: 36177757 DOI: 10.1177/03635465221113584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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16
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LaPrade RF, Engebretsen L, Lind M. Comparative Outcomes After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: Response. Am J Sports Med 2022; 50:NP53-NP54. [PMID: 36177756 DOI: 10.1177/03635465221113587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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17
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Kerzner B, Swindell HW, Terhune EB, Ramos P, Fortier LM, Dasari SP, Khan ZA, Gursoy S, Cancienne J, Chahla J. Medial Collateral Ligament and Posterior Oblique Ligament Reconstruction for Valgus Instability After Total Knee Arthroplasty. Arthrosc Tech 2022; 11:e1531-e1539. [PMID: 36185120 PMCID: PMC9519797 DOI: 10.1016/j.eats.2022.04.003] [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: 03/25/2022] [Accepted: 04/19/2022] [Indexed: 02/03/2023] Open
Abstract
Medial collateral ligament (MCL) injuries are typically managed non-operatively, with high rates of clinical success. However, patients who present with medial knee laxity with valgus stress testing of a fully extended knee, anteromedial rotatory instability, associated tibial plateau fracture, or multiligament injury or those who continue to be symptomatic after non-operative treatment may benefit from surgical intervention. Patients with a history of total knee arthroplasty who suffer MCL and posterior oblique ligament (POL) injuries represent a challenging patient population and often require surgical attention. In this Technical Note, we describe the preoperative assessment, decision making, and surgical technique for anatomic reconstruction of the superficial MCL and POL with an Achilles allograft in young, active patients with medial-sided knee injuries after total knee arthroplasty.
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Affiliation(s)
- Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Hasani W. Swindell
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Elizabeth B. Terhune
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Pablo Ramos
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Luc M. Fortier
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Suhas P. Dasari
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Safa Gursoy
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Jourdan Cancienne
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A,Address correspondence to Jorge Chahla, M.D., Ph.D., Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St, Suite 300, Chicago, IL 60612, U.S.A.
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Surgical Principles for Medial and Posteromedial Knee Injuries. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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