Management of the Medial Collateral Ligament in the Combined Ligament Injured Knee

Kyle Borque, Mary Jones, Andy Williams

Volume 5 | Issue 1 | Jan – April 2020 | Page 36-42

Author: Kyle Borque [1], Mary Jones [2], Andy Williams [2]

[1] Houston Methodist Hospital, Houston, TX, USA
[2] Fortius Clinic, London, UK

Address of Correspondence
Dr. Kyle Borque,
Houston Methodist Hospital, Houston, TX, USA.
E-mail: kaborque@gmail.com

Abstract

While isolated medial collateral ligament (MCL) injuries can frequently be treated non-operatively, in the setting of a multiple ligament injured knee, operative intervention is frequently required. The MCL’s biomechanical roles (primary restraint to valgus, secondary restraint to internal and external tibial rotation) must be taken into account when addressing the injured MCL. The authors prefer a combination of repair and reconstruction, with the goal of preserving proprioceptive feedback while also restoring mechanical support. The ideal surgical technique depends on the acuity and location of the injury. The goal of this paper is to provide a framework for approaching both operative and nonoperative treatment of MCL injuries in the setting of multiple ligament knee injuries.
Keywords: Medial collateral ligament (MCL), Knee dislocation, Multiple ligament knee injury, MCL repair, MCL reconstruction.

References

1. Alaia E, Rosenberg Z, Alaia M. Stener-Like Lesions of the Superficial Medial Collateral Ligament of the Knee: MRI Features. Am J Roentgenol. 2019;213(6):W272-W276.
2. Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate ligament: A long-term follow-up study. Am J Sports Med. 1992;20(1):7-12. doi:10.1177/036354659202000103.
3. Azar F. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sport Med Arthrosc Rev. 2006;2:84-90.
4. Bagwell MS, Wilk KE, Colberg RE, Dugas JR. the Use of Serial Platelet Rich Plasma Injections With Early Rehabilitation To Expedite Grade Iii Medial Collateral Ligament Injury in a Professional Athlete: a Case Report. Int J Sports Phys Ther. 2018;13(3):520-525. doi:10.26603/ijspt20180520.
5. Battaglia MJ, Lenhoff MW, Ehteshami JR, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: A biomechanical evaluation in a cadaveric model. Am J Sports Med. 2009;37(2):305-311. doi:10.1177/0363546508324969.
6. Coltart W. Pellegrini-Stieda lesion. Proc R Soc Med. 1938;31(03):180-181.
7. Eirale C, Mauri E, Hamilton B. Use of platelet rich plasma in an isolated complete medial collateral ligament lesion in a professional football (soccer) player: A case report. Asian J Sports Med. 2013;4(2):158-162. doi:10.5812/asjsm.34517.
8. Engebretsen L, Lind M. Anteromedial rotatory laxity. Knee Surg Sport Traumatol Arthrosc. 2015;23(10):2797-2804.
9. Fanelli GC, Edson C. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy. 2002;18(7):703-714.
10. Fetto J, Marshall J. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res. 1978;132:206-218.
11. Geeslin A, LaPrade RF. Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: a prospective case series and surgical technique. J Bone Jt Surg Am. 2011;93(18):1672-1683.
12. Harner C, Buoncristiani A, Tjoumakaris F. Master Techniques in Orthopaedic Surgery: Reconstructive Knee Surgery. Third ed. Lippincott, Williams & Wilkins Inc; 2008.
13. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20(5):499-506. doi:10.1177/036354659202000503.
14. Holden DL, Eggert AW, Butler JE. The nonoperative treatment of Grade I and 11 medial collateral ligament injuries to the knee. Am J Sports Med. 1983;11(5):340-344. doi:10.1177/036354658301100511.
15. Hughston J. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Jt Surg Am. 1994;76(9):1328-1344.
16. Kennedy J, Fowler P. Medial and anterior instability of the knee. An anatomical and clinical study using stress machines. J Bone Jt Surg Am. 1971;53(7):1257-1270.
17. LaPrade RF, Bernhardson AS, Griffith CJ, MacAlena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial knee ligament injuries: An in vitro biomechanical study. Am J Sports Med. 2010;38(2):330-338. doi:10.1177/0363546509349347.
18. LaPrade RF, Engebresten A, Ly T, Johansen S, Wentorf F, Engebretsen L. The anatomy of the medial part of the knee. J Bone Jt Surg Am. 2007;89(9):2000-2010.
19. LaPrade RF, Terry GC. Injuries to the Posterolateral Aspect of the Knee. Am J Sports Med. 1997;25(4):433-438. doi:10.1177/036354659702500403.
20. Laprade RF, Wijdicks CA. Development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012;470(3):806-814. doi:10.1007/s11999-011-2061-1.
21. Levy BA, Fanelli GC, Whelan DB, et al. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17(4):197-206. doi:10.5435/00124635-200904000-00001.
22. Lian J, Patel N, Nickoli M, et al. Obesity Is Associated with Significant Morbidity after Multiligament Knee Surgery. J Knee Surg. 2019;10:1055/s-0039-1681027.
23. Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures: A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med. 1996;24(2):160-163. doi:10.1177/036354659602400207.
24. Mancini EJ, Kohen R, Esquivel AO, Cracchiolo AM, Lemos SE. Comparison of ACL Strain in the MCL-Deficient and MCL-Reconstructed Knee during Simulated Landing in a Cadaveric Model. Am J Sports Med. 2017;45(5):1090-1094. doi:10.1177/0363546516685312.
25. Maor D, Jones M, Lee J, Dunn A, Williams A, Calder J. Prolotherapy as a treatment choice for lateral ankle ligament injuries in elite athletes: A case series. Act Orthop Belgica. 2020;Accepted f.
26. Marchant MH, Tibor LM, Sekiya JK, Hardaker WT, Garrett WE, Taylor DC. Management of medial-sided knee injuries, part 1: Medial collateral ligament. Am J Sports Med. 2011;39(5):1102-1113. doi:10.1177/0363546510385999.
27. Reider B, Sathy MR, Talkington J, Blyznak N, Kollias S. Treatment of Isolated Medial Collateral Ligament Injuries in Athletes with Early Functional Rehabilitation: A Five-year Follow-up Study. Am J Sports Med. 1994;22(4):470-477. doi:10.1177/036354659402200406.
28. Robinson JR, Sanchez-Ballester J, Bull AMJ, Thomas R de WM, Amis AA. The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Jt Surg – Ser B. 2004;86(5):674-681. doi:10.1302/0301-620X.86B5.14853.
29. Shirakura K, Terauchi M, Katayama M, Watanabe H, Yamaji T, Takagishi K. The management of medial ligament team in patients with combined anterior cruciate and medial ligament lesions. Int Orthop. 2000;24(2):108-111. doi:10.1007/s002640000119.
30. Standard Nomenclature of Athletic Injuries. In: American Medical Association, Subcomittee on Classifcation of Sports Injuries. ; 1966.
31. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surgery, Sport Traumatol Arthrosc. 2019;27(8):2450-2459. doi:10.1007/s00167-018-5237-3.
32. Yoshioka T, Kanamori A, Washio T, et al. The effects of plasma rich in growth factors (PRGF-Endoret) on healing of medial collateral ligament of the knee. Knee Surgery, Sport Traumatol Arthrosc. 2013;21:1763-1769.
33. Zhu J, Dong J, Marshall B, Linde M, Smolinski P, Fu F. Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surg Sport Traumatol Arthrosc. 2018;26:550-557.

(Abstract)      (Full Text HTML)      (Download PDF)