SLARD Symposium: MCL´s Injuries ISAKOS – 11 th Biennial Congress

Tue June 6th 2017 13:30 – 14:15

Shanghai, China

Gustavo A. Rincón, MD – Chairman Department Orthopedic Surgery

Hospital de San José – Bogotá - Colombia Assistant Professor, Knee Unit – FUCS

President Sports Medicine Chapter Colombian Orthopedic Society

§ Practice profile:

o Location: academic medical center (32 residents and 3 fellows) o Research: Clinical, Basic Science o Years in practice: 15 o Number of repair / augmentation MCL’s /yr: 6-8 o Number of reconstruction MCL’s /yr: 4-6

§ Anatomy

o MCL has 3 components 1. Superficial Medial Collateral Ligament

• One femoral attachment and two tibial attachments 2. Posterior Oblique Ligament

• Fibrous extensión of the distal aspect of the semimembranosus • Reinforces the posteromedial aspect of the joint capsule • Three fascial attachments at the knee joint

3. Deep Medial Collateral Ligament • Thickened of the medial aspect of Joint capsule. Two

components: • Meniscofemoral and Meniscotibial

§ Biomechanics o Superficial MCL is the primary restraint to valgus laxity of the Knee o Posterior Oblique Ligament functions as an internal rotator and valgus

stabilizer at between 0 and 30 degrees of knee flexion o Complementary relationship between sMCL and POL o Deep MCL is valgus stabilizer at 60 degrees and provide restraint

against external rotation torque between 30-60 degrees.

o Classification o Accordance with the amount of laxity at 30 degrees of knee flexion

with a valgus applied moment: (subjective gapping of the medial joint line)

• Grade 1+ 3 to 5 mm • Grade 2+ 6 to 10 mm • Grade 3+ > 10 mm

§ Diagnosis

o Mechanism of injury involving a contact or non contact valgus force o Pain and swelling along the medial aspect of the knee (femoral,

midsubstance, tibial) o Chronic injuries: Instability with cutting and pivoting maneuvers

§ Image evaluation

o Valgus stress radiographs useful for quatitive grading o Magnetic Resonance Imaging is commonly used to identify place of injured MCL, other injuries to the knee, trabecular micro fractures and bone bruises

§ Treatment

o Non Operative • Favorable outcome specially femoral and midsubstance injuries • Early controlled motion, protected valgus stress and external

rotation (4-6 weeks) • Functional rehabilitation program

o Operative • Repair (Acute)

- Primary repair - Recover tibial attach

• Repair with augmentation (Acute) • Reconstruction Tecniques (Chronic)

“Don´t use hamstrings”

§ Postoperative Rehabilitation o Motion of the knee as soon as posible (High risk of arthrofibrosis) o Weight bearing is encouraged when pain has subsided o Strengthening exercises o Hinged brace for 6-8 weeks o Return to sports 6-9 months

§ Conclusions: o Not all MCL injuries are the same o Most isolated MCL injuries are still treated non-operatively o Surgical decision regarding repair tibial attach is important in acute

cases with medial instability. o Repair, or repair with augment is useful in the setting of multilig.

injuries o Reconstruction just for chronic cases.

§ Case Examples

1. MCL repair tibial attach o 26 years o ACL-MCL injury during soccer game o AL/AM instability o Pain at tibial insertion MCL

o ACL reconstruction + MCL repair

2. MCL repair o 49 years o Motorcicle accident o Dislocated Knee o ACL/PCL/MCL. No vascular injury.

(video) (video)

o MCL repair • Joint capsule • Meniscotibial Lig • sMCL

• Protect infrapatellar branch of saphenous nerve

(Video)

3. MCL repair & augmentation (POL)

o 53 years o Construction site accident o ACL/PCL/MCL No vascular injury o Dislocated Knee

(Video)

o “Dimple sign”: Buttonholding of femoral condyle through capsule

o MCL repair • Joint capsule • Meniscofemoral Lig • MPFL • sMCL

o POL (Augmentation with Allo Tib. Ant.)

(Video) (Video)

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