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MCL,LCL & ALL injuries of the knee
The document discusses the anatomy, evaluation, and treatment options for medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries, including both operative and non-operative approaches. It highlights the healing responses of the MCL and outlines indications for surgical intervention, such as multi-ligament injuries and chronic instability. Treatment protocols, rehabilitation guidelines, and grading systems for ligament injuries are also included, emphasizing the complexity of knee injuries and the importance of accurate diagnosis and management.
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MCL,LCL & ALL injuries of the knee
- 1. MCL,LCL & ALLinjuries Mohamed Abulsoud (M.D) Lecturer of orthopedic surgery Al-Azhar university Cairo- Egypt AOTRAUMA international faculty
- 2. Learning outcomes •To understandthe relevant anatomy of the side ligaments of the knee •To study the mechanism of injury of each ligament and how to diagnose such injury •To highlight the different treatment options in acute or chronic situations
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- 6. Function • The sMCLis the main valgus stabilizer of the knee in all flexion angles • The dMCL ia a secondary valgus stabilizer and has a minor role in the prevention of anterior tibial translation. • The POL acts as a stabilizer of valgus, internal and external rotation of the knee in extension.
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- 9. • Pellegrini Stiedalesion
- 10. Radiological Evaluation • Themedial collateral ligament (MCL). is evaluated primarily on the coronal fat–saturated T2 or (STIR) sequences.
- 11. Radiological Evaluation • Grade1 intact ligament, normal in signal, with surrounding edema and/or hemorrhage . • Grade 2 partial rupture, abnormal signal within the ligament itself and/or fluid surrounding the ligament in the MCL bursa • Grade 3 complete rupture, frank disruption and discontinuity of the ligament
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- 13. •Stener like lesion RadiologicalEvaluation
- 14. Treatment Non operative treatment •Isolated injury to the MCL results in a robust healing response • Rich blood supply, • Relatively wide surface area, • Association with other secondary stabilizers, • Extra-articular location. • 80 % return to sports within 9 weeks , 20 % hidden meniscal or ACL injuries Holden DL, Eggert AW, Butler JE: The nonoperative treatment of grade 1 and 2 medial collateral ligament injuries to the knee. Am J Sports Med 1983. • 91 % return to sports after grade 3 injury Jones RE, Henley MB, Francis P: Non-operative management of isolated grade III collateral ligament injury in high school football players. Clin Orthop 213:137, 1986.
- 15. Indications of operativetreatment • open injury • MCL entrapment causing incongruent reduction of the tibiofemoral joint • fracture avulsion of the MCL origin • distal MCL avulsion and pes anserinus interposition (a ‘Stener’ lesion) • multi-ligament knee injury (the timing of this is controversial) • other injuries requiring surgery (e.g. meniscal tear ,ACL) • chronic instability after non-operative management
- 16. Anatomic double bundleMCL reconstruction Anatomic single bundle MCL reconstruction Non Anatomic double bundle MCL reconstruction
- 17. Non Anatomic doublebundle transfer (modified Bosworth)
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- 19. Am J SportsMed 37(6):1123, 2009.
- 21. Wijdicks CA, GriffithCJ, LaPrade RF, et al. J Bone Joint Surg Am. 2009;91(3):521-529.
- 22. Rehabilitation • Protected WBin hinged knee brace • 0 to 90 ° for 2 weeks • Gradual flexion 6 weeks • Discontinue brace after 6 to 8 weeks • Avoid pivoting for 16 weeks • Jogging 16 to 20 weeks • Return to play 9 months
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- 25. • The LCLis the primary stabilizer to varus stress of the knee. • The PFL provides an important restraint to external rotation. • Popliteus is dynamic stabilizer +/- static LCL & PLC
- 26. Mechanism of injury •Varus, Rotation, extension • 75% combined injury (PCL, ACL or both ) • CPN injury 15 %
- 27. Clinical Evaluation • Varusstress test
- 28. Clinical Evaluation • ExternalRotation–Recurvatum test
- 29. Clinical Evaluation • Theprone external rotation test (dial test ) • Performed at both 30 and 90 degrees of knee flexion
- 30. X ray • Stressviews • Arcuate sign • Avulsion fractures
- 31. Radiological Evaluation • Mostcommonly, LCL injury manifests as complete midsubstance disruption with surrounding soft tissue edema. • Injury to the LCL complex can be graded on MRI, Grade 1 :- Edema surrounding an intact ligament . grade 2 :-Intrasubstance ligamentous signal, possibly with ligamentous thickening or thinning and surrounding edema. grade 3 :-Frank disruption and discontinuous fibers
- 32. Radiological Evaluation • thepopliteus muscle and tendon are best evaluated with both sagittal and coronal MRI sequences. • They are most commonly injured at the musculotendinous junction • in the setting of a traumatic knee injury and subsequent MRI, the popliteus can be considered the “window to the posterolateral corner.”
- 33. Fanelli A FanelliB Fanelli C Increase External rotation Increase external rotation and mild varus instability Significant rotational and varus instability Isolated injury to PFL Injury to PFL and partial FCL Complete injury to PFL, FCL, and cruciate ligaments PFL reconstruction Arciero Laprade Vs Arciero
- 34. Treatment Repair • Within 2-3weeks • Failure rate 38% • Geeslin et al, AJSM 2016
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- 41. History • As earlyas 1879, Paul Segond described a ‘‘pearly, resistant, fibrous band’’ at the anterolateral aspect of the knee. • This eponymous Segond fracture was reported to occur in the tibial region above and behind the Gerdy’s tubercle
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- 45. Indications for combinedreconstruction • Patients with high-grade pivot shifts on preoperative examination • Recurvatum > 10 ° • Chronic ACL lesion • Revision cases • Participation in pivoting sports • Associated Segond’s fracture • Lateral femoral notch sign Feucht et al COP 2016
- 46. Combined ACL, ALLpreconstruction
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