Medial Collateral Ligament Injuries of the Knee Dr. (Prof.) Anil Arora MS (Ortho) DNB (Ortho) Dip SIROT (USA) FAPOA (Korea), FIGOF (Germany), FJOA (Japan) Commonwealth Fellow Joint Replacement (Royal National Orthopaedic Hospital, London, UK) Senior Knee and Hip Replacement Surgeon Associate Director Department of Orthopaedics and Joint Replacement Max Superspeciality Hospital, Patparganj, Delhi (India) E-mail : [email protected]
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Medial Collateral Ligament Injuries of the Knee Ligament... · Medial collateral ligament "tibial" injuries: indication for acute repair. Orthopedics. 2004;27(4):389–393. • Nakamura
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Medial Collateral Ligament Injuries of the Knee
Dr. (Prof.) Anil Arora
MS (Ortho) DNB (Ortho) Dip SIROT (USA)
FAPOA (Korea), FIGOF (Germany), FJOA (Japan)
Commonwealth Fellow Joint Replacement
(Royal National Orthopaedic Hospital, London, UK)
Senior Knee and Hip Replacement Surgeon
Associate Director
Department of Orthopaedics and Joint Replacement
Max Superspeciality Hospital, Patparganj, Delhi (India)
Internal fixation should not be used in areas where normal
gliding of the ligament is required during flexion and
extension.
Neither the screw with toothed washer nor the staple should
be overly tightened or countersunk
Approximating sutures apposing the dissected torn edges of
the ligament should be reinforced with tension sutures of non
absorbable material.
Surgical tips
Surgical tips
The superficial medial collateral ligament is tightened at
30 of knee flexion
The posterior oblique ligament is tightened at
0 degree of knee flexion
Rehabilitation program after Repair
The initial range-of-motion exercises (2 weeks)
Prevent adhesion formation;
Extension is allowed to 0
Avoid both hyperextension and flexion past 90
After the initial two weeks
Knee flexion to a full range of motion
No resistive or repetitive hamstring exercises for
approximately four months after the reconstruction
After the initial six weeks of protected weight-bearing
Closed kinetic- chain exercises
Rehabilitation program after Repair
Once full weight-bearing is permitted at the seven-week
Special attention must be paid to the restoration of
normal gait mechanics
Must observe the gait pattern closely
Ensure that the patient is not employing a quadriceps-
avoidance pattern with a hyperextension thrust at the
knee joint during stance phase.
It is also critical that the patient avoid
Posting the foot of the surgically treated extremity lateral
to the base of support in stance in an attempt to unload
the joint
Illustration-1
• Manoj 24/M
• RTA
• ACL, MCL ruptured
• Depressed # Lat. Tibia
MRI
Treatment
• Tibial fixation of MCL
• Repair of PMC, distal most limb of SMCL
• Elevation of depressed tibial condyle
• Filling of void with bone graft
• Across the knee Ex. Fix
Surgical scar
Postop 3 months
Postop 3 months
Postop 3 months
12 months follow up MRINicely reconstituted MCL
Illustration-2
• Vimal, 31/M
• RTA
• Medial opening on valgus
• MCL avulsion femoral side
MRI
MRI
Treatment
• Anatomical restoration of MCL
• Fixation by staple
• Early mobilization
• Protected weight bearing
• QUAD. Exercises
8 weeks postop
12 weeks postop
12 weeks postop
12 weeks postop
Illustration-3
• Sunil,38/M
• RTA
• Medial joint pain
• Give-way
• Apprehension of fall
• Difficult to walk
Postop X-ray
6 Wks
12 Wks
A square or rectangular pattern is used in the manner of
a mattress suture to secure the tension sutures.
Careful alignment of the tension sutures along the
course of the ligament fibers is necessary
Tension sutures can be tested for functional placement
and isometry during flexion and extension before being
tied definitively.
Surgical tips
Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L.Force measurements on the posterior oblique ligament and superficial medialcollateral ligament proximal and distal divisions to applied loads.
Am J Sports Med. 2009;37:140-8.
Aim of an operative repair or reconstruction of the superficial
medial collateral ligament is to restore the distinct functions of
both divisions by reattaching the two tibial attachments in an
attempt to reproduce the overall function Of the superficial
medial collateral ligament construct.
Goal-oriented rehabilitation program treated conservatively
Initial treatment
• Apply ice with compressive wrap for 20 minutes and repeat every 3-4 hours for the first 24-48 hours.
• Apply minimally restrictive lateral hinge brace (grade II or III injuries).
• Dispense crutches; allow weight bearing as tolerated.
Subsequent treatment
• Begin active range-of-motion exercises in cold whirlpool at least twice daily.
• Begin straight-leg raises and electrical muscle stimulation (if available).
• Maintain general conditioning with upper body ergometer or swimming.
Goal-oriented rehabilitation program treated conservatively
• Goal one: Walking unassisted without a limp
• Goal two: 90 degrees of knee flexion
• Goal Three: Full knee motion
• Goal four: Complete entire running program in one session
Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996;21(2):147–156.