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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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Saithna A, Helito CP, Bin Abd Razak HR, Cristiani R. Secondary restraints in ACL reconstruction: State-of-the-art. J ISAKOS 2024; 9:759-768. [PMID: 38734309 DOI: 10.1016/j.jisako.2024.05.001] [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: 03/27/2023] [Revised: 03/07/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
At-risk patients continue to experience a high likelihood of graft rupture after anterior cruciate ligament (ACL) reconstruction (ACLR). This narrative review seeks to provide the reader with an evidence-based synopsis of state-of-the-art concepts related to secondary restraint lesions, and how addressing them surgically might result in improved outcomes of ACLR.
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Affiliation(s)
- Adnan Saithna
- Department of Orthopedic Surgery, University of Arizona, Tucson, AZ, 85724, USA; AZBSC Orthopedics, 7649 E Pinnacle Peak Rd, Scottsdale, AZ, 85255, USA.
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333 - Cerqueira Cesar, São Paulo, SP, CEP: 05403-010, Brazil; Hospital Sírio Libanês, Rua Dona Adma Jafet, 91 - Bela Vista, São Paulo, SP, CEP 01308-050, Brazil
| | - Hamid Rahmatullah Bin Abd Razak
- Total Orthopaedic Care & Surgery, Novena Medical Centre, 10 Sinaran Drive, 307506 Singapore; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, 20 College Road, Academia Level 4, 169865, Singapore
| | - Riccardo Cristiani
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden; Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
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Pinheiro VH, Laughlin M, Borque KA, Ngo D, Kent MR, Jones M, Neves N, Fonseca F, Williams A. Career Length After Surgically Treated ACL Plus Collateral Ligament Injury in Elite Athletes. Am J Sports Med 2024; 52:2472-2481. [PMID: 39097768 DOI: 10.1177/03635465241262440] [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: 08/05/2024]
Abstract
BACKGROUND Limited data are available regarding career length and competition level after combined anterior cruciate ligament (ACL) and medial- or lateral-sided surgeries in elite athletes. PURPOSE To evaluate career length after surgical treatment of combined ACL plus medial collateral ligament (MCL) and ACL plus posterolateral corner (PLC) injuries in elite athletes and, in a subgroup analysis of male professional soccer players, to compare career length and competition level after combined ACL+MCL or ACL+PLC surgeries with a cohort who underwent isolated ACL reconstruction (ACLR). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A consecutive cohort of elite athletes undergoing combined ACL+MCL and ACL+PLC surgery was analyzed between February 2001 and October 2019. A subgroup of male elite soccer players from this population was compared with a previously identified cohort having had isolated primary ACLR without other ligament surgery. A minimum 2-year follow-up was required. Outcome measures were career length and competition level. RESULTS A total of 98 elite athletes met the inclusion criteria, comprising 50 ACL+PLC and 48 ACL+MCL surgeries. The mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Return-to-play (RTP) time was significantly longer for ACL+PLC injuries (12.8 months; P = .019) than for ACL+MCL injuries (10.9 months). In the subgroup analysis of soccer players, a significantly lower number of players with combined ACL+PLC surgery were able to RTP (88%; P = .003) compared with 100% for ACL+MCL surgery and 97% for isolated ACLR, as well as requiring an almost 3 months longer RTP timeline (12.9 months; P = .002) when compared with the isolated ACL (10.2 months) and combined ACL+MCL (10.0 months) groups. However, career length and competition level were not significantly different between groups. CONCLUSION Among elite athletes, the mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Professional soccer players with combined ACL+PLC surgery returned at a lower rate and required a longer RTP time when compared with the players with isolated ACL or combined ACL+MCL injuries. However, those who did RTP had the same career longevity and competition level.
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Affiliation(s)
| | - Mitzi Laughlin
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Dylan Ngo
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Madison R Kent
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Mary Jones
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Nuno Neves
- Orthopaedic Department, Hospital CUF Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
| | | | - Andy Williams
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
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Peez C, Hägerich LM, Ruhl F, Klimek M, Briese T, Glasbrenner J, Deichsel A, Raschke MJ, Kittl C, Herbst E. Collateral ligament strain is linearly related to coronal lower limb alignment: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38932622 DOI: 10.1002/ksa.12340] [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: 02/15/2024] [Revised: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The purpose of this study was to analyse the influence of coronal lower limb alignment on collateral ligament strain. METHODS Twelve fresh-frozen human cadaveric knees were used. Long-leg standing radiographs were obtained to assess lower limb alignment. Specimens were axially loaded in a custom-made kinematics rig with 200 and 400 N, and dynamic varus/valgus angulation was simulated in 0°, 30°, and 60° of knee flexion. The changes in varus/valgus angulation and strain within different fibre regions of the collateral ligaments were captured using a three-dimensional optical measuring system to examine the axis-dependent strain behaviour of the superficial medial collateral ligament (sMCL) and lateral collateral ligament (LCL) at intervals of 2°. RESULTS The LCL and sMCL were exposed to the highest strain values at full extension (p < 0.001). Regardless of flexion angle and extent of axial loading, the ligament strain showed a strong and linear association with varus (all Pearson's r ≥ 0.98; p < 0.001) and valgus angulation (all Pearson's r ≥ -0.97; p < 0.01). At full extension and 400 N of axial loading, the anterior and posterior LCL fibres exceeded 4% ligament strain at 3.9° and 4.0° of varus, while the sMCL showed corresponding strain values of more than 4% at a valgus angle of 6.8°, 5.4° and 4.9° for its anterior, middle and posterior fibres, respectively. CONCLUSION The strain within the native LCL and sMCL was linearly related to coronal lower limb alignment. Strain levels associated with potential ultrastructural damages to the ligaments of more than 4% were observed at 4° of varus and about 5° of valgus malalignment, respectively. When reconstructing the collateral ligaments, an additional realigning osteotomy should be considered in cases of chronic instability with a coronal malalignment exceeding 4°-5° to protect the graft and potentially reduce failures. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Luise Maria Hägerich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Felix Ruhl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Matthias Klimek
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Peez C, Deichsel A, Zderic I, Richards RG, Gueorguiev B, Kittl C, Raschke MJ, Herbst E. Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024; 32:864-871. [PMID: 38454816 DOI: 10.1002/ksa.12110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. METHODS Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5° increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. RESULTS Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 N and 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 N and 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). CONCLUSION Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Niethammer TR, Aurich M, Brucker PU, Faber S, Diemer F, Pietschmann MF, Schoch W, Zinser W, Müller PE. Follow-up Treatment after Cartilage Therapy of the Knee Joint - a Recommendation of the DGOU Clinical Tissue Regeneration Working Group. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024. [PMID: 38224697 DOI: 10.1055/a-2206-7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e. g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place.
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Affiliation(s)
- Thomas R Niethammer
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | - Matthias Aurich
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Halle (Saale), Halle, Deutschland
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost, Halle (Saale), Deutschland
| | - Peter U Brucker
- ATOS Klinik München, München, Deutschland
- Biomechanik im Sport, Fakultät für Sport- und Gesundheitswissenschaft, Technische Universität München, München
| | - Svea Faber
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
| | | | - Matthias F Pietschmann
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
- OrthoPraxis Oberhaching, Oberhaching
| | | | - Wolfgang Zinser
- Orthoexpert, Knittelfeld, Österreich
- Metagil Physikalisches Ambulatorium, Knittelfeld, Österreich
| | - Peter E Müller
- Muskuloskelettales Universitätszentrum München (MUM), Klinik für Orthopädie und Unfallchirurgie, Klinikum der Universität München, LMU München, München, Deutschland
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Petersen W, Al Mustafa H, Buitenhuis J, Häner M, Braun K. Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon. Arthrosc Tech 2024; 13:102836. [PMID: 38312881 PMCID: PMC10838056 DOI: 10.1016/j.eats.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/07/2023] [Indexed: 02/06/2024] Open
Abstract
The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.
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Affiliation(s)
- Wolf Petersen
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Hassan Al Mustafa
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Johannes Buitenhuis
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Martin Häner
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Karl Braun
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
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Herbst E, Glasbrenner J, Deichsel A, Briese T, Peez C, Raschke MJ, Kittl C. [Injuries of the medial side of the knee : When and how should they be treated?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:18-26. [PMID: 37848564 PMCID: PMC10787005 DOI: 10.1007/s00113-023-01368-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/19/2023]
Abstract
Different medial structures are responsible for restraining valgus rotation, external rotation, and anteromedial rotation. When injured this can result in various degrees of isolated and combined instabilities. In contrast to earlier speculation, the posterior oblique ligament (POL) is no longer considered to be the main stabilizer of anteromedial rotatory instability (AMRI). Acute proximal medial ruptures are typically managed conservatively with very good clinical results. Conversely, acute distal ruptures usually require a surgical intervention. Chronic instabilities mostly occur in combination with instabilities of the anterior cruciate ligament (ACL). The clinical examination is a particularly important component in these cases to determine the indications for surgery for an additional medial reconstruction. In cases of severe medial and anteromedial instabilities, surgical treatment should be considered. Biomechanically, a combined medial and anteromedial reconstruction appears to be superior to other reconstruction methods; however, there is currently a lack of clinical studies to confirm this biomechanical advantage.
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Affiliation(s)
- Elmar Herbst
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Johannes Glasbrenner
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Adrian Deichsel
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Thorben Briese
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christian Peez
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christoph Kittl
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland.
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Pfeiffer TR, Günther D. [Treatment of acute knee dislocations]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:35-43. [PMID: 37815539 DOI: 10.1007/s00113-023-01369-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/11/2023]
Abstract
A knee dislocation is a serious injury involving at least two of the four major ligamentous stabilizers of the knee. This injury results in multidirectional knee instability. In dislocation of the knee the popliteal artery and the peroneal nerve can also be damaged. Dislocations with vascular involvement are potentially threatening injuries of the lower extremities. The diagnosis of knee dislocation can be difficult due to a high rate of spontaneous reduction at the initial examination. Knee dislocations are rare and mainly occur in young men. They are mostly caused by high-energy trauma; however, they can also be caused by low-energy injuries. Obesity increases the risk of knee dislocations. The classification of a knee dislocation is based on the anatomical structures involved and the direction of dislocation. The acute treatment includes reduction and stabilization measures. Associated injuries, such as vascular, nerve, extensor mechanism and cartilage injuries as well as fractures and meniscal injuries can influence the treatment approach and the outcome. The definitive surgical treatment depends on the severity of the injury and can include ligament reconstruction or repair with bracing. The aftercare should be individually adapted with the aim to restore knee joint stability and function. Complications such as arthrofibrosis, peroneal nerve palsy, compartment syndrome, postoperative infection and recurrent instability can occur. In the long term, patients have an increased risk for the development of symptomatic osteoarthritis.
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Affiliation(s)
- Thomas R Pfeiffer
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Klinikum Köln-Merheim, Universität Witten/Herdecke, Ostmerheimerstr. 200, 51109, Köln, Deutschland
| | - Daniel Günther
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Klinikum Köln-Merheim, Universität Witten/Herdecke, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
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Häner M, Petersen W. [Treatment of acute injury of the anterior cruciate ligament : Always only reconstruction?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:8-17. [PMID: 37597054 DOI: 10.1007/s00113-023-01357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/21/2023]
Abstract
The aim of treatment of a ruptured anterior cruciate ligament (ACL) is the return of the patient to an acceptable level of activity without giving way phenomena as well as adequate treatment of prognostically relevant concomitant lesions. The treatment of acute ACL ruptures can be either early reconstruction or a primary physiotherapy with optional later reconstruction. Which path is taken depends on possible concomitant injuries that require early surgical intervention (e.g., repairable meniscal injury or distal rupture of the medial collateral ligament) and on patient-specific factors (age, level of activity). Isolated ruptures of the ACL can also be primarily treated without surgery. Then the injured knee joint should first be so far conditioned by rehabilitative measures that pain, swelling and posttraumatic restriction of movement are improved and neuromuscular training can be started. A screening test consisting of jumping tests, patient-reported outcome measures and the testing for giving way phenomena can be suitable to differentiate compensators (copers) from noncompensators (non-copers). Surgical reconstruction of the ACL should be recommended to non-compensators in the sense of participatory decision-making. Activity modification (adapter) can also be considered as a treatment strategy. If instability events (giving way) or secondary meniscal lesions occur during nonsurgical therapy, cruciate ligament reconstruction should be considered.
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Affiliation(s)
- Martin Häner
- Sportklinik Berlin und Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar-Theyß-Str. 27-31, 14193, Berlin, Deutschland
| | - Wolf Petersen
- Sportklinik Berlin und Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar-Theyß-Str. 27-31, 14193, Berlin, Deutschland.
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Von Rehlingen-Prinz F, Leiderer M, Dehoust J, Dust T, Kowald B, Frosch KH, Izadpanah K, Henes FO, Krause M. Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries. SPORTS MEDICINE - OPEN 2023; 9:70. [PMID: 37553489 PMCID: PMC10409938 DOI: 10.1186/s40798-023-00611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.
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Affiliation(s)
- Fidelius Von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Miriam Leiderer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Tobias Dust
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Birgitt Kowald
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Editorial Commentary: The Timing and Treatment of Combined Anterior Cruciate Ligament-Medial Collateral Ligament Injuries: Conservative Management, Early Repair, Augmentation, and Delayed Reconstruction of the Medial Collateral Ligament. Arthroscopy 2023; 39:1108-1110. [PMID: 36872028 DOI: 10.1016/j.arthro.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/23/2022] [Accepted: 09/09/2022] [Indexed: 03/07/2023]
Abstract
Medial collateral ligament (MCL) injuries are commonly encountered in conjunction with anterior cruciate ligament injuries. MCL tears do not universally heal, and residual MCL laxity is not always well tolerated. Although residual MCL laxity results in excess stress on an anterior cruciate ligament reconstruction and may require additional treatment, relatively little interest has been paid to concomitant treatment. Adherence to the dogma of universal conservative treatment of MCL tears in this setting squanders opportunities for preservation of native anatomy and improvements in patient outcomes. Although we currently lack the necessary information to provide evidence-based decision making for combined injuries, the time has come to renew both clinical interest and research interest in pursuing better management of these injuries in high-demand patients.
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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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Li W. Effect of Rehabilitation Physical Training on PE Teaching Sports Injury under Ultrasonic Examination. SCANNING 2022; 2022:1470303. [PMID: 36189143 PMCID: PMC9509252 DOI: 10.1155/2022/1470303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/27/2022] [Accepted: 09/05/2022] [Indexed: 06/16/2023]
Abstract
In order to solve the problem of the effect of rehabilitation physical training on physical education teaching injury, a method based on ultrasonic examination of rehabilitation physical training on physical education teaching injury effect observation method is proposed. In this method, the ISOMED isokinetic muscle strength test, the body shape test, the balance ability test, the lower limb explosive power test, and other methods are used to evaluate the knee joint of patients systematically, and the specific rehabilitation physical training plan is formulated to achieve the treatment purpose. The experimental results show that after the targeted training, a series of indicators on the affected side increase significantly: the power increases by 45.6%, the force increases by 8.3%, and the speed increases by 38.7%. It is concluded that the muscle strength, shape, balance ability, and lower limb explosive power of patients are significantly improved, which lays a solid foundation for athletes to recover smoothly and achieve good competition results.
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Affiliation(s)
- Wangda Li
- School of Physical Education, Ankang University, Ankang, Shaanxi 725099, China
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Bhimani R, Lubberts B, DiGiovanni CW, Tanaka MJ. Dynamic Ultrasound Can Accurately Quantify Severity of Medial Knee Injury: A Cadaveric Study. Arthrosc Sports Med Rehabil 2022; 4:e1777-e1787. [PMID: 36312723 PMCID: PMC9596904 DOI: 10.1016/j.asmr.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/02/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To quantify the severity of medial knee injuries based on medial compartment gapping as measured by stress ultrasonography. Methods In 8 cadaveric knees, the distance between the medial tibial and femoral condyles was measured using ultrasonography. These measurements were obtained in the intact state and repeated after open sequential transection of the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), posterior oblique ligament (POL), and arthroscopic transection of the anterior cruciate ligament (ACL). Knees were evaluated at 0° and 20° of knee flexion using the Telos device under 0 N and 100 N of valgus force. Receiver operating characteristic curve analysis and the DeLong test were used to determine whether measurements could distinguish between successive severity of MCL injury after identifying the optimal cutoff value for each injury state. Results Of the 8 cadaveric knees included in this study, 3 were male and 5 were female. The mean age was 58 ± 11 years (range 48-82 years). When measured using ultrasonography at 20° knee flexion with valgus load, the medial tibiofemoral distance significantly increased with increasing severity of medial knee injury (P values ranging from .049 to <.001). The optimal cutoff values for distinguishing between an intact knee and sMCL injury were 8.3 mm (area under the curve [AUC] = 0.98), between sMCL and dMCL injury 9.9 mm (AUC = 0.89), dMCL and POL 16.7 mm (AUC = 0.88), and POL and ACL 18.6 mm (AUC = 0.84). When we compared combined intact and sMCL-transected stages with dMCL-transected stage, the optimal cut-off point to differentiate stable from unstable injuries was equal to 13.8 mm of medial tibiofemoral distance (AUC = 0.97; sensitivity = 100%; specificity = 94.1%). Conclusions Dynamic ultrasonographic assessment can accurately quantify the severity of medial knee ligament injury based on medial compartment gapping. In our study, we found medial tibiofemoral distance >13.8 mm at 20° knee flexion under valgus force indicates the presence of dMCL injury with a diagnostic accuracy of 0.97. Clinical Relevance Dynamic ultrasonography can quantify severity of medial knee injury without radiation and at point of care in multiple clinical settings.
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Madi S, Acharya K, Pandey V. Current concepts on management of medial and posteromedial knee injuries. J Clin Orthop Trauma 2022; 27:101807. [PMID: 35242534 PMCID: PMC8873958 DOI: 10.1016/j.jcot.2022.101807] [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: 01/27/2022] [Revised: 02/06/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
Traditionally, while managing ligament injuries around the knee, medial side injuries are frequently overlooked or considered 'benign' with very little influence on overall knee stability outcomes. However, much has changed in the recent past, and like the lateral side of the knee, it is gaining considerable attention. It is now well known that the Medial collateral ligament and Posteromedial corner are fundamentally two distinct structures that differ in anatomy and biomechanics. When it comes to decision making between conservative versus operative approach for medial side injuries, treating orthopaedic surgeons are subjected to walking on a thin line trying to balance between potential residual laxity and joint stiffness. This review will delve into some of the recent works focusing on the medial side injuries and discuss the evolving concepts.
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Affiliation(s)
| | | | - Vivek Pandey
- Corresponding author. Sports injury and arthroscopy division, Orthopaedics, Kasturba medical college, Manipal, Manipal academy of Higher education, Manipal, 576104, India.,
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